Inspection on 09/06/06 for St Mary`s Residential Home

This inspection was carried out on 9th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Mary`s Residential Home 02/05/07

St Mary`s Residential Home 31/01/07

St Mary`s Residential Home 26/01/06

St Mary`s Residential Home 14/04/05

St Mary`s Residential Home 26/01/05

St Mary`s Residential Home 11/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Mary`s Residential Home North Walsham Road Crostwick Norwich Norfolk NR12 7BQ Lead Inspector Ruth Hannent Unannounced Inspection 9th June 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Residential Home Address North Walsham Road Crostwick Norwich Norfolk NR12 7BQ 01603 898277 01603 891105 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) County Healthcare Ltd, a wholly owned subsidiary of Four Seasons Health Care Ltd Linda Bowker-Howe Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Forty-four (44) Older People of either sex, not falling into any other category, may be accommodated. 26th January 2006 Date of last inspection Brief Description of the Service: St. Marys is a large single storey building situated in the village of Crostwick.The accommodation consists of thirty-two single and six double bedrooms. Thirty-three bedrooms have an en suite facility. There are a variety of communal areas for the use of service users.St. Marys is situated in its own grounds with a large car park to the front of the premises. Email - st.marys@fshc.co.uk. Fees - £385 - £435 per week. St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place with the Deputy Manager over a period of five hours looking at all the key standards as written in the ‘Care Homes For Older People’‘ National Minimum Standards’. The Inspector had received many letters and comment cards of concerns and complaints over the past few months from families, residents and a GP, which were used as part of this inspection of the service. Residents and families were spoken to during the day who were also unhappy making comments on the way the Home was being run. Records looked at were care plans, health records, personnel files, supervision notes, maintenance records and rota’s. It was noted that very little attempt had been made to improve the service since the last inspection as requirements set had not been achieved although an action plan sent to the commission in March 2006 showed dates set for the requirements would receive attention and be completed by the end of April 2006. A tour of the building took place and a meal was overseen. What the service does well: What has improved since the last inspection? What they could do better: St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 6 Information and the recording of the care required for each resident needs a full review and clear details in place for all staff to follow on a format that is user friendly. The meals both in the dining room and served in bedrooms needs to improve with quality and choice. The Home needs to improve and develop a management style that is suitable for the service that it aims to deliver. A more stable staff team who are trained and supported, need to be in place to offer consistency of care for the residents. All records within the home need to be orderly and complete. Activities and stimulation need to be ongoing and often and all residents have this recorded in their care plans. Policies and procedures that are in place need to be implemented and some form of audit carried out to ensure these procedures are followed. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 and 5 The quality of this outcome is poor. This judgement has been made using available evidence including a visit to the Home. Residents have a minimal assessment carried out and felt their needs would be met by the information given. Although a visit to the Home by all interested parties does take place the type of staff needed are not always available or competent enough to offer the service required. EVIDENCE: The Deputy Manager was able to discuss the assessments carried out by the Manager prior to any resident being admitted but the written documents showed very little information and any care plans started from that information would not have held enough detail to ensure the care available within the Home would be the care required. (Requirement) St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 9 The residents recently admitted said they had visited prior to making a decision to stay and the talks they had with the Home had reassured them their care needs would be met. However due to a large turn over of staff and often new or agency staff being used the new residents stated that it was according to who was on duty whether their needs were met or not. (See requirement for standard 27) St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The quality of this outcome is poor. This judgement has been made using available evidence including a visit to this service. Care plans for each resident is limited and lacking information so gives poor details of the care required. The health care needs of residents are met. The medication procedures is a concern and needs to be reviewed to ensure the gap between each dose is correct. Record keeping is good. EVIDENCE: In each bedroom a file is in place to hold all the information/care requirements for each resident. On looking at three care plans during the inspection it was difficult to find information required. All had loose bits of paper, one person had no current care details, although, was now needing care in bed, no fluid charts to monitor intake of liquids, but did contain a turning chart that was completed, timed and dated. (Even these were individual loose records that were falling out of the file and could easily be misplaced). Some attempt had St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 11 been made to review the care plan but it was unclear if this had taken place monthly as required in the National Minimum Standards. On talking to a table of residents who were still eating breakfast at 10 o’clock they are often helped too late with getting up and would prefer to be up earlier so as the gap between meals is longer. (Dinner starts at 12.00). They all stated how busy the staff were and how they have to wait their turn and when asked if they have been offered choice of when they would like assistance they all stated they wait for when the staff are available. No details were found in the care plans on reading of person centred care. (Outstanding Requirement x 2) On the day of the inspection a nurse and health care assistant were in for a few hours of the day. On talking to one she was able to say staff supported the nurses who visit at least twice a week for various residents. One comment card received by the Inspector did show concerns by a regular health practitioner of the care ability of some staff within the Home. The health care records are stored in the locked medication room and a record is placed in the hand over book of which health professional has been to the Home and what action is required by the care staff. (Seen). The medication was all in order within the medication trolley. The many cupboards within the medication room were not inspected. The eye drops in the fridge were all in date. The controlled drugs record were looked at and all recordings were correct with two signatures and each tablet remaining was counted with the Inspector and was correct and held in a small separate locked cupboard. A concern shared with the Senior staff team was the timing of the administration of all drugs. In the morning the medication was still being issued at 9.30 and the next round was beginning at 12.15 with not enough time elapsing between doses of some residents medication. It was also discussed that a letter had been received from a concerned relative stating some night time medication is issued too early when there is no senior on duty meaning a resident is left with the tablet in their room or it is ingested too early for when that person would prefer to go to bed. During the inspection the administration of medication was changed to after dinner to give the gap of four hours between administrations and is to be discussed as a necessity for the future. (Requirement). It was noted throughout the day that residents were spoken to in a respectful manner and all doors were knocked upon before a staff member entered. The staff who have been in the Home for a long time have built up a good relationship with the residents and the conversations heard were appropriate and caring. Comments received by relatives were not so complimentary about the management approach to residents when the service provided was challenged. St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The quality of this outcome is poor. This judgement has been made using available evidence including a visit to this Home. The needs of individual residents with their social support/lifestyle is not addressed or recorded to meet their expectations. Residents do remain in contact and have visitors when and where they wish. The choice and control of many aspects of the resident’s life is controlled by the systems within the Home and autonomy and choice is not always available. The meals are lacking in choice and quality. EVIDENCE: On the day of the inspection a game of bingo was taking place with some residents and a designated staff member who comes to the home for three sessions of activities throughout the week. The stimulation provided is very limited and as one person stated ‘if you do not like bingo there is little else to do’. It was noted the mobile library had arrived and one resident had, with the Deputy’s help, managed to get some German books to read. A few residents talked about trips they use to have in the summer but no longer have them St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 13 nor the entertainment that would come in regularly to play or sing to them. The large lounge had all the chairs spread around the edge and the television was on with no one appearing to be listening or watching and too far away from most residents to be seen if they did want to watch. There was limited information in the daily records of who had been involved in social stimulation and again the social needs of individuals is not recorded on their care plan. (Requirement). Resident’s families and friends are welcomed and visit when they wish. On the day of the inspection at least six visitors arrived and met with the resident in whichever area they wished, using the garden, bedroom, lounge or conservatory (although as said by two relatives this is not always pleasant due to this area being used by smokers). They are usually made to feel welcome and are sometimes offered a drink. The residents have their money paid into a bank account and all bills are paid for and recorded correctly for items such as the hairdresser or newspaper account. It was difficult to ascertain if residents preferred to have their money managed this way as they have accepted this system. There was no evidence of a resident having their own control of their finances, the Home would only accept cash or cheques to be placed in the bank account (as discussed with the administrator) and no offer of assistance with using outside agencies such as advocacy. (Recommendation). On the day of the inspection the lunch-time meal was fish and chips with either battered or plain fish or the alternative was salad. It was noted that many residents were leaving the batter complaining it was too hard and one resident would have much preferred an egg but was ‘not allowed’. The residents had to ask for salt and vinegar and the tables were laid poorly with tatty table-mats and no cloths or napkins.(these were a recommendation two inspections ago). Two ply paper serviettes that were rough were available but two residents said they were ‘useless’. One resident was having a liquidized meal in bed and was being assisted by a staff member who had to be prompted by the inspector to explain and talk to the resident what she was offering on the spoon. Another relative had both on a comment card and spoken directly to the Inspector how poor the meals are and the lack of choice seemed to have disappeared. (Past requirements had been actioned from the last inspection showing a choice had been offered and a menu was shared with residents). A new cook had just started and quite a few residents were unhappy as the previous one had been, as four residents stated, ‘better’. (Requirement). St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality of this outcome is poor. This judgement has been made using available evidence including a visit to the Home. The Home is poor at accepting comments and complaints and residents and relatives do not feel they are listened to. Although staff are aware of abuse the training and more indepth understanding is not evident. EVIDENCE: Since the inspection in January of this year the Inspector has received six letters and numerous comment cards from families who are unhappy with the care their loved ones are receiving at St. Mary’s. Many of the comments are about how dissatisfied the relatives are with the way the management handle any criticism or complaint. On asking the Deputy manager if any complaints had been received within the Home no records were available nor have the Senior staff team written or recorded any comments/complaints to share with management if they have received them when they were on duty. The Manager had recorded that one complaint had been received by the Home on the pre inspection questionnaire but records were not available on the day of the inspection. The Home have recently had the second relatives/residents meeting where many voiced concerns but felt the answers in return were negative and nothing had changed. (Requirement). St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 15 The staff, according to the Deputy Manager, have been issued with booklets distributed by Four Seasons on the understanding and signs to look for on abuse. Although the staff, when questioned would be prepared to ‘whistle blow’ and the Home does have a policy on whistle blowing the completion of these booklets is yet to happen. The Deputy Manager has not yet seen any returned but as the Manager was on annual leave could not say definitely that none had been returned. No records were available. (Outstanding Requirement x 2) St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25 and 26 The quality of this outcome is adequate. This judgement has been made from using available evidence including a visit to the Home. The Home is maintained fairly well with an Officer who keeps his records up to date. The safety in some areas causes concern such as the temperature of the water and the lighting in the corridors presenting risks and needs to be improved. The Home is clean and hygienic. EVIDENCE: The inside of the building looked safe and maintained with bright areas in the lounges and dining rooms. The decoration is of a fair standard but some bathrooms need new flooring and decorating. The flooring being mentioned in the last inspection and has still not been improved. (Requirement). St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 17 The garden directly from the conservatory is in good order with cut grass and flower beds but this is a small area compared to the amount of land around the property which is in need of tidying and the grass cutting. There is nothing but green for residents who look out onto these areas with no flower beds or hanging baskets. (Recommendation) The Homes Maintenance Officer was able to show the records for water temperatures, fire alarm weekly checks, the dates of the fire departments visit and the recording of water boiler temperatures. The recording of water from bedrooms showed recordings of 48 degrees. This was regularly recorded over weeks of checking and on discussion with the Maintenance Officer has been a problem for a while and he is waiting for engineers to look at the boilers and help adjust the temperatures to the required 43 degrees. (Requirement). The lighting in the corridors is still very dim in parts that was a requirement on the last inspection and has not been improved. (Outstanding Requirement). As you walk down the corridor from a light area you move in and out of different patches of light and dark which was highlighted to the Inspector by watching a resident who has visual problems feeling a little unsure when walking along. On talking to this person she finds it very difficult walking from a bright lounge into the electric light of 60 wattage bulbs that in some areas are far apart. (Wattage checked). The domestic staff clean the Home well. An odour was detected in one bedroom that was not being used at present and the staff are trying to lift the problem with a good shampoo. The carpet that had caused problems in room 26 had been replaced before a resident was admitted. (seen).All bedrooms and communal areas were clean and each bedroom was tidy. Some en-suite bathrooms are still in need of floors replacing as they are stained but no unpleasant smell was detected. The laundry has two washing machines that cope with the laundry of the 37 residents. (One has a sluice cycle). It was clean and tidy and each resident had a basket for the fresh laundry to be placed in before returning it to the residents bedrooms. St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the Home. Residents are cared for by a variety of staff some that have the skills and some who need more experience and training. The service is not always consistent and residents needs are not always met. The amount of staff who have the recognised qualification is too low. The Management does not follow the full procedures when recruiting new staff. Some training is available but not all staff are competent in their jobs. EVIDENCE: The Home has had a large turn over of staff that has had an impact on the residents. On talking to them and reading the comments expressed by relatives the service does not have consistency or the skills over the whole twenty-four hours. Agency staff cover many shifts and noted at the inspection was a list of eleven shifts for the next week required by a agency.( All the Home staff had already been asked). New staff arrived have not had the experience or hold the skills of a good carer and this was reflected in eleven of the thirteen comment cards received along with comments saying the staff are working too many hours or the Home is understaffed. Whilst staff who have worked in the building a long time are praised for the work they do there are St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 19 not enough of them. On the day of the inspection the number of people on duty matched the number on the rota and residents seemed contented and although assisted to get up quite late were happy on that day. It was noted that seven residents all need two staff to assist them with care tasks and the rota needs to be looked at again to ensure the service can meet the needs at appropriate times. (Requirement) The Home has moved no further forward in staff achieving a recognised qualification in care. This was a requirement on the last inspection and more effort must be made to encourage staff and show the value of achieving such a qualification. (Outstanding Requirement). Two personnel files were picked at random from the filing cabinet. One had only a reference from a friend with no second reference and to date the CRB application had been completed (copy seen) but had not been returned. This person had been in post for a few weeks and was not supervised with all tasks involving residents. The other had only one reference with a CRB returned that week and had also been working for a couple of weeks. (Requirement). Staff training was happening in an adhoc way with notices in the staff room of what was available but records of who had trained and when refreshers had taken place was not recorded. (It was noted on some supervision notes that training would be in place for staff members but on asking a particular staff member who had received supervision no training had been received). (Outstanding Requirement) St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 The quality of this outcome is poor. This judgement has been made using available evidence including a visit to the Home. The Manager is struggling to deliver the responsibilities expected of this role. The quality assurance monitoring system needs to be more in depth. Residents financial interests are safeguarded. Staff are not always suitably supervised. The health and safety of residents and staff is promoted but needs improvement. EVIDENCE: St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 21 Many comments have been received by the commission since the last inspection on the lack of management skills held at St. Mary’s. (Six letters in total with numerous comments on the Commissions comment cards) Although they say the manager is ‘way out of her depth’ and ‘lacks leadership’ other comments state there is a ‘caring person’ who should not be in this position without ‘support and training’. The assessment/results for the management qualification is still awaited but to date has not been achieved with the portfolio still with the assessor. (Requirement). A type of quality assurance questionnaire was sent via Four Seasons to all the residents to assess the type of service they were receiving. The outcome found that this type of quality assurance monitoring, needs to be more in depth and include all interested parties within St. Mary’s to get a fuller picture of the service offered. An action plan from this small survey was not seen. To be able to produce an action plan and aims for the future a monitoring system must be more in depth to measure success and improve areas of weakness (Requirement). A record of the resident’s money kept within the bank account held for St.Mary’s was checked carefully. The administrator explained the system used and showed receipts and recordings for all resident’s money both in and out with signatures. Supervision notes were seen and records available for some staff had been completed but items to be covered such as training had not happened Although as mentioned earlier in the report some areas within the building need to be maintained to a better standard such as the hot water and lighting throughout the corridors, the records seen and the visual checks made the records are accurate and safe. The staff do need training that keeps them updated with new knowledge and skills within health and safety. The Commission does receive Regulation 37 reports and on checking with Senior staff and the accident book within the Home the reports received were correct. St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 x x x x x 2 3 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 2 x 3 X X 2 St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The Registered Manager must have clear documentation on a care plan that sets out how the needs of the service user will be met. (Outstanding Requirement x 2) The Registered Manager must deliver a recognised training programme to all staff on the Protection Of Vulnerable Adults (Outstanding Requirement x 2) The Manager must ensure that staff are supervised appropriately. (Outstanding Requirement x 2) The Manager must ensure that full details are recorded to ensure the service can meet the needs of the potential resident. The Manager must ensure that medication is issued in a timely, safe manner. The Manager must ensure suitable activities are arranged to suit the individuals. The Manager must ensure that DS0000027467.V299783.R01.S.doc Timescale for action 01/08/06 2. OP18 13.6 01/08/06 3. OP36 18.2 01/08/06 4 OP14 16.2 (m) 01/08/06 5 6 7 OP9 OP12 OP15 13.2 16.2(n) 16.2(i) 10/06/06 01/08/06 01/08/06 Page 24 St Mary`s Residential Home Version 5.2 8 9 10 OP16 OP19 OP25 22 23.2(b) 13.4(a) 11 12 OP25 OP27 23.2(i) 18.1a 13 OP29 Sch 2 14 15 16 OP30 OP33 OP36 18.1(a) 24 18.2 residents are offered wholesome meals that allow choice. The Manager must ensure that all complaints are dealt with appropriately and timely. The Manager must ensure that bathroom floorings that are stained or split be replaced. The Manager must ensure the water temperatures from resident’s area are kept at the recommended 43 degrees. The manager must ensure that the corridor lighting is suitable. (Outstanding requirement) The Manager must ensure that competent, qualified staff are working in the Home in sufficient numbers to meet residents needs.. The Manager must ensure that personnel files hold all paperwork required before employing staff. The Manager must ensure that staff are appropriately trained. The Manager must ensure a comprehensive quality assurance system is in place. The Manager must ensure that all staff are appropriately supervised. 01/08/06 01/09/06 01/08/06 01/08/06 01/09/06 01/08/06 01/09/06 01/09/06 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP14 OP15 Good Practice Recommendations It is recommended that residents have more choice in the way their money is handled within the Home. (Advocacy) It is recommended that the presentation of meals in the dining room needs to improve with the replacement of DS0000027467.V299783.R01.S.doc Version 5.2 Page 25 St Mary`s Residential Home 3 OP19 table mats and tablecloths. It is recommended that the grounds need to be tidied and the grass cut. St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Mary`s Residential Home DS0000027467.V299783.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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