Inspection on 15/04/08 for St Marys Nursing Home

This inspection was carried out on 15th April 2008.

CSCI found this care home to be providing an Adequate service.

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.

Other inspections for this house

St Marys Nursing Home 03/03/09

St Marys Nursing Home 09/08/07

St Marys Nursing Home 05/06/06

St Marys Nursing Home 10/11/05

St Marys Nursing Home 18/04/05

St Marys Nursing Home 26/10/04

St Marys Nursing Home 26/05/04

St Marys Nursing Home 07/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE St Marys Nursing Home 327 Main Rd Sidcup London DA14 6QG Lead Inspector Ms Pauline Lambe Key Unannounced Inspection 15th April 2008 09:00 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 Marys Nursing Home DS0000006772.V361251.R02.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 Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Marys Nursing Home Address 327 Main Rd Sidcup London DA14 6QG 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) 020 8302 7289 020 8460 7393 St Mary’s Care Home Ltd Mrs Giantee Lallchand Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places St Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing (CRH - N) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 20 9th August 2007 Date of last inspection Brief Description of the Service: St Marys Nursing Home is registered with the Commission for Social Care Inspection to provide nursing care for 20 Older People. The home is situated on a main road in a residential area of Sidcup close to local shops and bus routes. The detached two-storey house was not purpose built. It has five double and one single bedroom on the ground floor and nine single bedrooms on the first floor. One of the bedrooms has en suite facilities the remainder have washbasins with hot and cold water. Communal areas include a lounge, separate dining room, kitchen and laundry area. Adequate bathing, toilet and sluicing facilities are provided. At the rear of the building there is a garden for residents’ use, which is wheelchair accessible. Visitors can park on the front drive or in the side roads. The current fees ranged from £572.00 - £600.00. Residents paid privately for personal items, hairdressing and chiropody services. St Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection was carried out over two visits, one on 15th April 2008 and the second on 24th April 2008. At the first visit fourteen residents were in the home with six vacancies and at the second visit one resident had been admitted to hospital. The registered provider was in the home for a short period and spent time talking to the inspector on the first day and the manager was in charge on the second day and assisted with the inspection. The last key unannounced inspection was on the 9th August 2007. The inspection included a review of information held on the service file, a tour of the premises, inspecting records, talking to residents, relatives, staff and manager and reviewing compliance with previous requirements. Feedback on the service was obtained during the inspection from residents, relatives and staff and from some relatives following the inspection. The Commission did not send surveys to residents, relatives and staff for this inspection due to an administrative error. Feedback on the service was requested from local social service commissioners but no responses were received, as they had not undertaken monitoring visits due to the low number of residents they had placed in the home. Many areas of the service were managed satisfactorily and residents spoken with were satisfied with the quality of care provided. Staff were satisfied with their working conditions and the training and support they received. A number of concerns were noted in relation to medicine management and must be addressed to ensure resident safety. What the service does well: What has improved since the last inspection? All requirements and recommendations made at the last inspection were met or were being addressed. St Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 Page 6 Some bedrooms and corridors were repainted. Moving & handling risk assessments and moving & handling care plans included adequate guidance for staff. Medicine profiles were introduced for all residents. Activity sessions were regularly recorded. The standard of hygiene had improved. Employee references seen were verified as genuine. Individual training records for staff were introduced. 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. The summary of this inspection report can be made available in other formats on request. St Marys Nursing Home DS0000006772.V361251.R02.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 Marys Nursing Home DS0000006772.V361251.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3 and 4. Standard 6 does not apply to the service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were admitted based on an assessment of need and received written confirmation that the service was suited to meeting their needs. Resident contracts needed review to ensure compliance with regulation. EVIDENCE: Contracts were seen for some residents however these require amendments to ensure they comply with regulations 5 and 5a. The current contracts did not clearly show a breakdown of fees and who was responsible for specific payments. Requirement 1. The care records for a resident admitted since the last inspection included a pre admission assessment and a copy of the care manager’s assessment. Care records viewed included a copy of the letter to the resident stating that based on assessment the service was suited to meeting their needs. St Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans seen were satisfactory but could be further improved. Residents were generally supported to access healthcare when needed however this had not done for one person in a timely manner. Improvements were needed to medicine management. Based on observation and resident feedback where possible, residents were treated with respect. EVIDENCE: Care records for two residents were viewed. Both contained relevant personal details, risk assessments, assessments of need and care plans. Care plans reflected resident’s needs but in some instances lacked detail as to how these should be met. For example in relation to personal hygiene it was not clear if the person preferred a bath or shower or how often these were given, one care plan said to ‘encourage mobilisation’ but did not explain how this should be done or how often and another care plan said to ‘encourage regular use of the toilet’ but was not specific as to how to do this. Care plans were reviewed monthly and there was evidence to show they had been discussed with the resident or their representative. Care staff were observed moving an immobile St Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 Page 10 resident appropriately. Moving & handling risk assessments and care plans had improved and those seen provided adequate guidance for staff as to how the resident should be moved. Requirement 2. The care records seen included evidence of visits by external professionals such as the GP, dentist and optician. Pressure relief equipment was provided for residents assessed as needing this. It was noted that one resident had lost a lot of weight over the previous four months and there was no evidence to show that the person had been referred to the dietician or had their food intake monitored. A nutritional risk assessment had been completed but was incorrectly calculated as to the risk for the resident. The resident’s care plan had not been changed to reflect how their nutritional needs had changed and how these were to be met. On the second visit for this inspection it was noted that steps had not been taken to monitor this persons food intake. The manager said that this would start immediately. The manager had also referred the person to the dietician on the day after the first inspection visit. The provider’s Annual Quality Assurance Assessment (AQAA) said that an area of improvement in the last 12 months was that “nutritional assessment is reviewed regularly with the dietician input”. Relatives who could comment indicated satisfaction with the care provided and did not raise any concerns about this aspect of their lives. Requirement 3. Policies and procedures were in place in relation to medicine management. These were not dated so it was not possible to know when they were written or reviewed. Medicines were stored appropriately and a medicine fridge was provided. The temperature of the fridge was recorded daily but not the temperature of the storage room. Systems were in place to record receipt, administration and disposal of medicines. A medicine trolley was used to for administration and the home used the Boots blister packed system. A list of sample signatures was kept for staff responsible for administering medicines. One resident managed their eye drops only and a risk assessment and care plan was in place in relation to this. Medicine profiles were seen on both sets of care records viewed. Medicines and records were checked for five residents. The stock of one medicine for two residents did not tally with the amount dispensed, administered and remaining. One medicine for another resident was prescribed as a variable dose but as staff had not recorded the dose given the remaining stock did not tally with that dispensed and administered. Staff had not signed for two doses of one medicine for another resident and there was no way to check one medicine for a further resident as there was no record of receipt on the administration chart. Staff said that on the advice of the doctor they had made changes to the dose for one medicine for one person. Staff had not signed the changes on the administration record and when making the change had covered up the original dose, this made it difficult to complete an audit trail for that medicine. On the second day of the inspection the manager had taken action to correct some of the errors but had done this by transferring some medicines from one dispensed container to another. In house medicine audits were completed and records were seen for St Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 Page 11 audits on 16/1/08, 9/2/08 and 18/4/08. The manager addressed any issues noted from the audits with the staff team. A system was in place to assess staff competency using the Boots training record and there was evidence to show that some staff had received medicine training since the last inspection. Requirement 4. During the course of the inspection staff were observed interacting satisfactorily with residents. Most of the staff addressed residents by name and gave them time to respond. Residents who had ability and relatives spoken with said that they were satisfied with the way they were treated by staff. Care plans seen indicated staff encouraged resident independence and involvement in their care. Relative feedback indicated that all residents were in bed by 6:00 pm, which for some was a bit too early. Staff should discuss bedtimes with residents and ensure this meets their preference and is recorded on their night care plan. Recommendation 1. St Marys Nursing Home DS0000006772.V361251.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 – 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents who could comment were satisfied with their lifestyle. Visitors were welcome to visit at any time. Menus showed a varied diet was provided and no concerns were raised or noted about the meals provided. EVIDENCE: A daily activity programme was displayed n the lounge and showed that activities such as music & exercise, games to music, bingo and ball games were planned. A number of residents who could comment said they preferred to spend their time in their bedrooms and did not like to sit in the lounge or take part in activities. Other residents were quite frail and some unable to participate fully with activities. The service did not have a designated activity organiser and care staff organised activities in the afternoons as part of their role. Activities were recorded and records seen showed that one activity took place almost every afternoon. This was a group activity or one to one time spent with residents. During the two visits to complete this inspection the opportunity to observe activities did not occur. Residents who choose to continue their religious practices were supported to do this. The two sets of care records viewed had social care plans but these varied in content. For example one care plan said the person enjoyed soap operas and one to one St Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 Page 13 time having nail care but the other care plan said ‘encourage resident to mix with others and join in activities’ but it was not clear how this was to be done. Also the record did not have any detail on the person’s interests. Recommendation 2. The home had an open visiting policy and residents who could comment said they were happy to receive visitors in their bedroom or the communal lounge. Relatives seen in the home or who provided feedback indicated satisfaction with the visiting arrangements. Staff and management said they encouraged residents to make decisions about their lives and efforts were made to record resident and relative involvement in care planning. Residents who were able to voice their opinions said they were satisfied with the way care was delivered. A number of residents were unable to voice their views of the service. The kitchen was generally clean and tidy but the units were worn, chipped and some areas no longer waterproof. The cooker was quite old and did not work properly on occasions. The manager said that a new cooker was ordered but she could not locate the order form nor did she have a date for the cooker to be fitted. A join in the flooring had separated and required repair to ensure hygiene standards were not compromised. The toaster was rusty and needed to be replaced. The manager said that the kitchen was deep cleaned by staff but there was no record seen for this. Adequate supplies of fresh, frozen and dried foods were seen. Records were seen for freezer, fridge and food temperatures and a cleaning schedule was seen and was up to date. Menus seen indicated a varied diet was provided and a choice of meal offered to residents. Residents were having breakfast at the start of the inspection. Various cereals and cooked foods were prepared for the residents. During lunch staff were observed being attentive to residents and assisting them as needed. Meals were covered when being served and were not served to residents requiring assistance until staff were ready to provide assistance. Pureed foods were served separately and a number of residents required assistance with feeding. Some residents said they enjoyed their meal and others were observed enjoying the meal. A full and a part time cook were employed to provide daily and evening cover seven days a week. Care plans included nutrition risk assessments and there was evidence to show that residents weight was monitored monthly. A number of residents were prescribed additional food supplements. Please also read the comments under standard 7 and requirement 3 in relation to nutrition. Requirements 5 and 6. St Marys Nursing Home DS0000006772.V361251.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies, procedures and records were in place in relation to management of complaints and safeguarding adults. Residents and relatives indicated they knew who to talk to if they had a concern. EVIDENCE: No changes had been made to the complaints policy and procedure since the last inspection. Residents and relatives spoken with knew how to make a complaint. A system was in place to record complaints made about the service and to show how these were investigated. No complaints had been made about the service to the registered person or the Commission since the last inspection. Copies of the Bexley Safeguarding Adults Procedures, ‘alerter’s’ guide and a copy of the DOH document ‘No Secrets’ were provided. Allegations or suspicions of abuse were referred to Bexley Social Services for investigation. Staff who spoke to the inspector displayed an understanding of adult protection and how they would manage such an incident. Since the last inspection there were no safeguarding allegations received by the manager or the Commission. The manager said that a training session on safeguarding adults was booked for staff to attend in the near future. The Local Authority provided this training. St Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Work was in progress to upgrade the environment. Residents and relatives did not raise concerns about the environment and some commented on the improvements made to date. EVIDENCE: The inspection included a tour of the premises and review of a selection of maintenance records. Overall the home was maintained to a satisfactory standard. However the kitchen required some refurbishment and updating (see comments under standard 15). Work had commenced on repainting bedrooms and most of the bedrooms on the first floor and some on the ground floor had been repainted. The manager said that once the decoration work was completed new carpets would be laid where needed and the repainting programme completed on the ground floor. The manager completed regular health & safety audits. Time was spent talking to the registered provider who said he planned to continue with the refurbishment programme, which included St Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 Page 16 replacing soft furnishings and furniture. This information was also included in the AQAA completed by the provider. The AQAA indicated that some new carpets and furniture had been purchased however the manager said that this was planned and would be done once the decoration work was finished. The rear garden was neat and tidy and accessible to wheelchair users. The exterior of the home was satisfactorily maintained. The Commission will continue to monitor the implementation of the maintenance improvement programme at future inspections. Recommendation 3. A number of bedrooms were viewed and found to be clean and tidy. Some residents said their rooms had been repainted but they were not involved in the choice of colour. However they did not object to the colours used. The home was clean and tidy, sluice facilities were provided and staff had access to protective clothing and hand washing facilities. St Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 – 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Records showed adequate staffing levels were maintained and over 50 of care staff had achieved NVQ 2. Improvements had been made to training records and recruitment procedures. EVIDENCE: The staff team comprised of a registered manager, registered nurses, care assistants and domestic staff who worked together to meet the needs of the residents. Staff rotas seen showed that satisfactory staffing levels were maintained. Comments made by residents and relatives included “the staff are friendly” and “staff are very nice”. No concerns about staffing levels were raised by residents, relatives or staff spoken with. Eleven care assistants were employed, eight had achieved NVQ level 2 training or above and three were working towards this qualification. This information was included in the AQAA. Recruitment files for three staff employed since the last inspection were viewed. These showed that staff had been recruited in line with regulation. The manager had verified that references received without a company stamp or on headed paper were genuine. A system was in place to check that nurses employed were registered with the Nursing & Midwifery Council and this was last done on 22/4/08 for all nurses in post. St Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 Page 18 Staff who spoke to the inspector said they had access to training relevant to their roles. The manager said that she and some of the nurses provided inhouse training and that she also arranged external training courses for staff. Since the last inspection individual staff training records had been commenced. Two of these were seen and showed staff had 3 days training in the last year on topics relevant to their work. The manager said that training sessions on fire safety, dementia care and safeguarding adults were planned to take place in the near future. St Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Efforts had been made to obtain relative and resident feedback on the service. Safety records were well maintained and showed attention was given to providing a safe environment. EVIDENCE: The manager was registered with the Commission, had managed the service for some time and had the qualifications, skills and experience needed to manage the service. Meetings were held with relatives and staff and limited minutes kept in a diary. A relatives meeting was held on 18/3/08 and staff meetings on 16th, 17th and 18th March 08 to feedback information from the relatives meeting. Residents had recently completed satisfaction surveys with the help of staff or relatives. St Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 Page 20 A number of residents were not able to voice their views of the service at resident meetings or in questionnaires but other residents had this ability. No concerns were raised in the questionnaires about the service or the care provided. Regulation 26 reports were sent to Commission or kept in the home. In-house audits were completed on areas such as medicines, health and safety and accidents. A review of the service was sent to the Commission last year and the manager said that it was planned to collate all the information received about the service and prepare a new report for this year. Nobody in the home acted as an appointee for a resident. Staff managed personal allowances for a few residents in relation to hairdressing and chiropody care. Relatives provided money for residents and receipts were kept for money received and spent. Adequate records were kept and were made available to relatives and residents as needed. From the information provided in the AQAA and records seen during the inspection attention was given to providing a safe environment for residents and others. Safety systems such as servicing of the fire alarm, hoists, assisted baths, gas and electricity were up to date. The fire alarm was tested weekly and fire drills were held at times to include all staff. The manager said that fire drills were held three monthly and the last drill for day staff was in 12/07 and for night staff 10/07. Maintenance records showed that hot water temperatures were maintained within safe limits. A system was in place to record accidents to residents and others and accident forms seen were completed satisfactorily. There was a system in place to record follow up action taken when residents were involved in an accident or sustained an injury. Since the last inspection one resident had attended A&E following an accident however this had not been reported under regulation 37 to the Commission. The manager completed a monthly accident audit, which covered areas such as the resident’s name, date and type of accident. Requirement 7. St Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 St Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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 2 Standard OP2 OP7 Regulation 5a 15 Requirement Timescale for action 03/07/08 3 OP8 12 4 OP9 13 All residents must have a contract that complies with the requirements of this regulation. Care plans must be prepared 19/06/08 with residents and clearly state how assessed needs are to be met. Residents must be referred to 05/06/08 healthcare professionals when needed to ensure all precautions are taken to prevent a decline in their health status. Accurate records must be kept 05/06/08 for all medicines received into the home. Staff must sign and date changes made to medicine instructions on administration charts. When a variable dose of a medicine is prescribed staff must record the dose given. Staff must take care when making amendments on administration records so that any amendments made allow the original instructions and information to be clearly seen. Medicines must not be DS0000006772.V361251.R02.S.doc Version 5.2 St Marys Nursing Home Page 23 5 OP15 23 6 7 OP15 OP38 23 37 transferred from the original dispensed container to another. Medicine records must be kept in such a way as to enable an audit trail to be completed. Staff must not overstock medicines. The temperature of the medicine storage room must be monitored. The damaged kitchen units must be repaired or replaced and all units must be impermeable. The flooring must be repaired where needed. The toaster in the main kitchen must be replaced. Notices must be sent to the Commission as required by this regulation. 24/07/08 05/06/08 05/06/08 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 Refer to Standard OP10 OP12 OP19 Good Practice Recommendations Night care plans should be discussed with residents and address the time they want to go to bed and get up in the morning. Individual social care plans should ensure residents are supported to participate in meaningful activities based on their interest, preference and choice. A copy of the refurbishment programme with completion dates for work should be sent to the Commission to assist with monitoring progress. St Marys Nursing Home DS0000006772.V361251.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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