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Inspection on 01/07/05 for St Marys Nursing Home

Also see our care home review for St Marys Nursing Home for more information

This inspection was carried out on 1st July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a new manager, Ms Dobbin, who is hard working and committed to raising standards and making improvements. Following the fed-back from the inspection she was pro-active and implemented some necessary changes immediately. The Staff team are a mixture of staff who have worked at the home for sometime, and new recruits. Staff spoke of being a happy team and feeling settled now. A member of staff stated that it had been a hard few months but was worth it as things are much better now. Another said that being aware of how to complain and the homes whistle blowing policy made her feel secure and valued. Service users at the home are treated with respect and dignity and are able to make a lot of personal choices about how they are looked after. If service users like particular food, the cook tries to provide it for them. For example one service user requested ice cream for breakfast and this had been made available. Service users have their meals in their rooms if they want to. Meals are varied, well balanced and nicely presented. All of the service users have individualised single bedrooms.

What has improved since the last inspection?

Since the last inspection there have been a number of improvements in the home. Staff have had training and are being supported to take responsibility for care practices. A decision was made to remove the category of dementia from the registration certificate with a possibility of reviewing it when the home was in a more stable phase and staff had completed the necessary training. Ms Dobbin has a clear sense of leadership and vision for the home and is keen to become the registered manager. She has, in a short space of time, identified and ordered additional equipment that will support staff in caring for the service users. Menus have been reviewed and food and drink is made available at anytime it is requested. All staff files had been reviewed and additional information requested. Staff files now include sufficient information to ensure that a member of staff, prior to being recruited, can be checked to ensure that there is no known reason why they should not be employed to work with vulnerable adults. All staff have been made aware of the policy for the protection of vulnerable adults and their role in ensuring that service users are not at risk of abuse.

What the care home could do better:

The senior staff, on each of the floors, should arrange their staff so that service users are not left unattended for long periods. For example if four carers pair up into two teams of two to support service users in their bedrooms the others could be with those who are in the lounge doing activities or talking to them. This would address the concerns of service users who reported that they wished staff were not so busy and had more time to talk. The plan to ensure that all of the service users have an adjustable beds must be fully actioned and all additional mattresses removed from service users bedrooms. Service users should review care plans, where it is appropriate. Staff should also detail in the care plans or in a care diary the next date a dressing or a catheter change is due to ensure that planned care is not forgotten.

CARE HOMES FOR OLDER PEOPLE St Marys Nursing Home 19 Dunstable Road Luton Beds LU1 1BE Lead Inspector Sally Snelson Unannounced 1st July 2005 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 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 Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Marys Nursing Home Address 19 Dunstable Road Luton Beds LU1 1BE 01582 438200 01582 484116 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) ANS Homes Limited . Care home with nursing 60 Category(ies) of DE(E) Dementia over 65 - 60 registration, with number OP Old Age - 60 of places St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19.04.05 Brief Description of the Service: St Marys Care Home is a purpose built residential home situated in central Luton on the site of an old hospital. The home provides single bedroom accommodation for service users over the age of 65years. The original building has been extended to provide 60 bedrooms on two floors accessed by a shaft lift. There is an open courtyard area with seating and plants for interest and colour. There is adequate staff and visitor car parking space. The rooms are varied, with some in the older part of the building having retained features of the original hospital. A number of communal rooms provide a choice of seating areas. Two teams deliver the care, each covering one floor. The services provided include social and nursing care. The staff teams are made up of carers and qualified nurses. Care is provided for older people with physical disability. St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 1st July over a period of seven and a half hours. It was an unannounced inspection and followed an additional visit to the home 19th April 2005. The manager, who was awaiting registration with the CSCI, was present throughout the majority of the inspection. As part of the inspection methodology the inspector spoke to the manager, the deputy manager, staff, including ancillary staff, service users and visitors. The care of three service users was looked at in detail. What the service does well: The home has a new manager, Ms Dobbin, who is hard working and committed to raising standards and making improvements. Following the fed-back from the inspection she was pro-active and implemented some necessary changes immediately. The Staff team are a mixture of staff who have worked at the home for sometime, and new recruits. Staff spoke of being a happy team and feeling settled now. A member of staff stated that it had been a hard few months but was worth it as things are much better now. Another said that being aware of how to complain and the homes whistle blowing policy made her feel secure and valued. Service users at the home are treated with respect and dignity and are able to make a lot of personal choices about how they are looked after. If service users like particular food, the cook tries to provide it for them. For example one service user requested ice cream for breakfast and this had been made available. Service users have their meals in their rooms if they want to. Meals are varied, well balanced and nicely presented. All of the service users have individualised single bedrooms. St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: 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 Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 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 standard(s) 1,3 and 6 A thorough pre-admission assessment ensured, that only those service users whose needs could be met by the staff team and the available equipment in the home, would be admitted to St Mary’s Nursing Centre. EVIDENCE: The home had recently requested a change to the registration certificate. This change had been made, and the certificate sent to them, but had not been displayed. It is an offence not to display a current registration certificate under section 28 of the care standards Act. The change to the registration was to allow the home to take service users over the age of 65years with nursing needs only and not those with a primary diagnosis of dementia. This management decision had been taken following re-assessment of all the service users by their placing authority after concerns were raised and addressed. Those service users with dementia who were already accommodated when the change was made would remain in the home with sufficient staff, experienced in dementia care, to meet their needs. Those same staff would ensure that service users who went on to develop dementia once they have been admitted would have their needs met. St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 9 The Statement of Purpose was displayed in the entrance, along with a photograph album of recent activities and events that had taken place in the home. The deputy manager confirmed that all service users were offered a copy of the Service Users Guide; however none of the service users spoken to were aware of this document. The home had been through a period of not taking admissions; this embargo had recently been lifted. The manager or the deputy manager took responsibility for assessing new service users. It was noted that recent preadmissions assessments had been completed appropriately. The manager stated that she had felt under pressure to admit some of the service users she had been asked to assess but was clear that the assessment tool, along with her knowledge of the skills and qualifications of the staff, would influence her decision. She had recently had to refuse a service user whose ethnic background was different from any of the staff team or other service users, as this would result in communication problems with him and his family. At the time of the inspection St Mary’s did not provide intermediate care. St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 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 standard(s) 7,8 and 9 Care had been delivered in accordance with the service users care plan. Lack of forward planning could result in some episodes of care being omitted. EVIDENCE: The manager had a clear vision for the care of the service users. She held meetings weekly with the deputy manager and the senior nurses from each of the floors and expected the senior nurses to take responsibility for the clinical needs of the service users. For example the manager required the senior nurses to review dressings and medication at regular intervals and report any problems or changes to herself or the deputy. This was a system that had only recently been put into place, so it efficacy would be inspected as part of the next inspection. Sampling of care plans suggested that appropriate care plans were in place, however some of the plans lacked detail. For example a plan for a service users who had no dentures did not, as part of the food and drink care plan, suggest how this was to be managed. Where dressings or catheters were required to be changed at regular intervals, other than by counting back, there St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 11 was no documentation as to when this should happen next. At the time of the inspection this had not caused any problems but there was a potential for this to happen. All service users had been regularly weighed, assessed for nutrition and the risk of developing pressure areas. The Waterlow score of one service user did not corresponded to the pressure relieving equipment provided. The deputy manager confirmed that the service user had refused to have her mattress changed. This was obviously putting her at risk of developing a pressure sore and the reason for the correct equipment not being used must be documented. There was evidence that care plans were being reviewed every month. The home had a system whereby care plans were reviewed by all the staff on the particular floor. This was done, by reviewing the plan for the service user accommodated in the bedroom of the particular date, as part of the handover. For example on the 1st of every month all the staff discussed the plan for the service user accommodated in room one and so on. The inspector witnessed a 2pm. handover session and was concerned that the senior nurse did not record some of the useful information carers were reporting about the conditions of the service users they had cared for during the morning. There were also comments made during the hand-over that could have been discussed by the trained staff and used as a teaching session, to ensure that carers were aware of particular conditions. Those medication charts sampled had been completed appropriately and the necessary documentation for the receiving and administration of medication had been completed. The inspector noted that where a code had been used to state why a medication had not been given the code had been given more than one meaning. For example a code ‘F’ had been used for not required and to indicate out of stock on the same chart. The back of the MAR chart had not been completed. This meant that the inspector was unable to ascertain which drug was not required and which was out of stock without referring to the blister packs. It was noted that the daily temperature was recorded in the room where the medication trolley was stored. The inspector noted that that on two consecutive days the temperature had been above 25 degrees, which is considered to be the maximum temperature for the storage of medication to ensure efficacy. The nurse was not able to relate how this could be avoided in future heat waves. The manager had arranged to meet with a number of local pharmacists to secure the best service for the home. St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 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 standard(s) 12,13 and 15 An activity co-ordinator organised a programme of varied activities that met the needs of some of the service users. Service users were offered a varied nutritious menu to choose from. EVIDENCE: It was noted that a weekly activity plan was displayed. The plan was varied and included different activities for the morning and the afternoon including some one-to-one activities. The inspector witnessed happy hour on the Friday of the inspection. The happy hour offered those service users who wished, and whose medication allowed, to have an alcoholic or non-alcoholic drink from a mobile ‘bar’. It was noted that the service users participation in activities was recorded in their care plan. The inspector believed that one activity coordinator would find it difficult to provide sufficient meaningful activities for 60 service users. One service user was pleased to show the inspector her computer, which she described as her communication with the outside world. On the day of the inspection three of the service users were celebrating their birthdays. Staff had put banners and balloons outside each of their bedrooms. The cook told the inspector that she was looking forward to decorating the St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 13 large cake she had made for them. This was to be shared with the other service users during the afternoon, with a cup of tea. All service users had a drink beside them, whether they were in their bedroom or in the lounge. Those service users that had woken early had been offered tea before their breakfast. Breakfast was served to service users on trays either in their bedrooms, in the dining room or in one of the lounges. Service users had been asked to make a choice the day before and the inspector noted different combinations of cereals, porridge, sausage and tomato, toast and sandwiches being served. Those service users who needed help were being supported to eat their breakfast appropriately. One service user had requested ice cream for breakfast and this was provided for her, which she was really pleased about. Service users on the ground floor did not appear to use the dining room for breakfast; they either stayed in their bedrooms or the lounge. On the first floor the service users were taken to the dining room as they got up so that they were ready for breakfast. This resulted in some service users having to sit at the table for sometime before their breakfast was served. It was also noted that no staff were available to stay with service users in the dining room because they were assisting others to get up. Both dining rooms were used at lunchtime. For lunch most service users had tomato soup followed by fish and jam tart with alternatives available for those who did not like fish. Sampling of the menus suggested that the menus were planned to be nutritious. The cook stated that, as required at the last inspection, she had a place booked on a course to learn more about providing nutritious diets to service users with swallowing difficulties. The new manager had also arranged for a representative from a company providing food supplements to meet with the cook to give her ideas on adding high calorie supplements to normal diets. St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 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 standard(s) 16 There was a robust complaints procedure advertised throughout the home that outlined how service users or visitors could make a formal complaint. EVIDENCE: Above the signing in book was a holder containing complaints forms which visitors could complete if they did not want, or were unable, to speak to staff about their concerns. The complaints procedure was robust and promised a response in an acceptable time-scale. The inspector was aware of one complainant, who had made a complaint to the company at the end of last year; this complainant had still not received what the complainant believed to be a satisfactory response to the situation. Legal support had been involved. Staff, via notice boards, were made aware of the company’s harassment and whistle blowing policies; both referred to a free-phone company hotline, if needed. St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19,20,21,24,26 The layout of the home and the single accommodation offered service users a homely environment in which to live. EVIDENCE: All of the service users were accommodated in single bedrooms that had suitable furniture and fittings. The maintenance man had decorated empty rooms and there was a programme of refurbishment throughout the home. It was noted that some of the bedrooms had damage to the walls caused by manoeuvring wheelchairs and hoists. The garden area, although not large, had colourful courtyard areas with seating. Bedrooms were connected to an intercall system. The system displayed the number of the room that needed attention and also centrally recorded the time it took for the call-bell to be answered. The manager reviewed the information from this system. St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 16 The new manager had identified that not all of the beds were adjustable. She had installed six new beds and was planning to order a further five. Some of the divan beds had an additional mattress placed on the original mattress to raise the level. The manager agreed to remove one of the mattresses, or risk assess the situation, until all the hospital beds were in place. It was also noted that old mattresses were being stored in service users rooms; this was not acceptable. The manager believed that the additional mattresses were being used as protection for those service users at risk of climbing and falling over bedsides. She was planning to acquire at least one bed that could be lowered to seven inches above the floor in order to prevent falling, but could be raised when providing personal care. The bathrooms had been brightened with the addition of framed pictures. In one of the bathrooms where a soap dispenser had been moved, the skirting board blow the dispenser was particularly grubby. The soap dispenser leaking and dirt ‘sticking’ to the skirting board may have caused this. However it was obvious that this had built up over a period of time. The remainder of the home was clean and tidy and the inspector was aware of a team of ancillary staff cleaning throughout the day. Some of the drinks trays in the lounge had ants around them. The cleaner stated that this was the responsibility of the maintenance person. He confirmed that he had discussions with the pest control department and was doing whatever he could to stop them. Staff were being reminded to clear up spillages, particular sugary drinks, immediately. St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The home had robust recruitment procedures that protected service users. The manager had a strong commitment to training to ensure that experienced and suitable qualified staff would meet the service users’ needs. EVIDENCE: It was noted that all staff had been given the date they were to attend mandatory training such as moving and handling. The manager had made it clear that this training was not optional and staff that failed to attend would be disciplined. The manager stated that mandatory training was not on target and that she was prioritising this area while continuing to ensure that more specialist training was also made available. Specialist training, for example wound care training was being delivered in focused sessions. The wound care training was planned in four elements including wound infection, the healing process, an update on wound care and a session on the challenge of a leg ulcer. Staffing levels were such that the needs of the service users should be met. However the inspector noted that for some periods throughout the day service users, particularly those in the lounges and dining room, were left unattended. With a new manager appointed, the deputy manager would now be able to assume her role as training co-ordinator and the over-seeing of the care practices of all grades of staff. St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 18 The inspector sampled two staff files. The recruitment practices were thorough and complete and all the information required was in place. Now that the embargo on admissions had been lifted the home was in the process of recruiting both carers and trained staff. It was noted that the home had had a successful recruitment drive and were short-listing for all the posts. St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,38 The home had recently recruited an experienced and committed manager whose strong leadership and safe working practices ensured that service users health, welfare and safety were safeguarded. EVIDENCE: A month prior to the inspection a new manager had been appointed. She had been the registered manager in another of the company’s homes and had number of years experience working with the elderly in care home settings. A member of staff reported that ‘in a short space of time she has made an impression on the home, and appeared to be fair’. She was in the process of completing her application to become the registered manager. Relatives meeting were advertised to take place every two months. These meeting were themed, for example the first was to meet the new manager and the second was to discuss catering. The manager confirmed that other issues St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 20 would be included in these meetings as they arose. There were also qualified staff meetings planned in addition to whole staff meetings. Supervision records were not sampled at this inspection, however the manager confirmed that by devolving some of the supervision to other senior staff they were keeping on top of it. The manager was committed to training. She had made sure that she kept her own training up to date and was committed to achieving and maintaining high standards within the home. A deputy manager, who in the past had taken the lead in training, supported her. All required testing of systems and equipment had been carried out and the home had good policies and procedures in place in relation to safe working practices. All necessary risk assessments had been undertaken and staff were able to describe the action they would take in the event of a fire in the home. The fire safety officer had carried out a safety check on 31.05.05 where there were no outstanding requirements. During the inspection the inspector was given a copy of the last Regulation visit undertaken by the provider. This report should sent monthly directly to the CSCI. St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x 2 x 2 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 3 x x x x 3 St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 22 no Are there any outstanding requirements from the last inspection? 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 22 Regulation 13 Requirement Service users must have a means of summoning assistance in an emergency when sitting in the lounge. Timescale for action Originally 30th June 2005 extended to 1st September 2005. 01.09.05 2. 7 15 3. 9 17 4. 5. 6. 7. 24 24 27 33 16 16 18 26 Care plans must set out detailed action to be taken by the staff that includes dates for the next course of treatment Medication charts must be completed accurately, including the reverse of MAR sheets if this is necessary. Adjustable beds must be provided for all service users. Additional mattresses must be removed from divan beds Service users should not be left unattended in lounges and dining rooms. Regualtion 26 reports should be forwarded to the CSCI office after completion. 01.09.05 01.01.06 01.08.05 01.08.05 01.08.05 St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 23 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. 3. 4. 5. Refer to Standard 1 9 13 31 37 Good Practice Recommendations Service users should be made aware of the service users guide. Staff should be aware of the action to take if the area that medication is stored in is recorded above 25 degrees. Staff should be aware of providing sufficient activities for those service users who do not, or are not able, to enjoy communal activiities. The should complete the registration process as soon as possible. Staff handover should be documented. St Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Clifton House 4a Goldington Road Bedford MK40 3NF 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 Marys Nursing Home I51 S17693 St Marys V233568 010705 Stage 4.doc Version 1.30 Page 25 - 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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