Inspection on 06/05/08 for St Marys Nursing Home

This inspection was carried out on 6th May 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 12/04/07

St Marys Nursing Home 06/06/06

St Marys Nursing Home 23/11/05

St Marys Nursing Home 01/07/05

St Marys Nursing Home 11/11/04

St Marys Nursing Home 15/06/04

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE St Marys Nursing Home 19 Dunstable Road Luton Bedfordshire LU1 1BE Lead Inspector Kathy Jones Unannounced Inspection 6th May 2008 09:45 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 DS0000017693.V364163.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 Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Marys Nursing Home Address 19 Dunstable Road Luton Bedfordshire LU1 1BE 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) 01582 438200 01582 484116 winfielo@bupa.com www.bupa.co.uk BUPA Care Homes (ANS) Ltd Vacant post. Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60) of places St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users admitted prior to 01/06/05 may have a diagnosis of dementia. Up to 10 service users can be admitted under the age of 65. Date of last key inspection 12th April 2007. Brief Description of the Service: St Mary’s Care Home is a purpose built nursing 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 where in the summer plants provide interest and colour. The bedrooms are varied; some in the older part of the building have retained their original features. A number of communal rooms provide service users with a choice of seating areas. There is adequate staff and visitor car parking space. Staff are divided into two teams to deliver care, each team covering one floor. The staff teams are made up of qualified nurses, carers and senior carers supported by teams of housekeeping and administrative staff. Fees for this service start at £546.00 per week for those funded by Social Services, and private rates are £785.00 per week. These rates then vary depending on the individual needs required. St Marys Nursing Home DS0000017693.V364163.R01.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. Standards identified as ‘key’ standards and highlighted through the report were inspected. The key standards are those considered by the Commission to have a particular impact on outcomes for residents. Inspection of the standards was achieved through review of existing evidence, pre-inspection planning, an unannounced inspection visit to the home, collating information received in surveys received from relatives, people who use the service and drawing together all of the evidence gathered. The pre-inspection planning was carried out over the period of half a day and involved reviewing the service history, which details all contact and correspondence with the home and previous inspection reports. The last full inspection took place in April 2007, however an inspection was carried out in December 2007, which focussed on specific issues raised through safeguarding procedures. Information from these inspections was taken into account as part of the planning. This unannounced inspection visit was carried out by two inspectors and covered the morning and afternoon of a weekday. The inspection was carried out by ‘case tracking’, which involves selecting samples of residents’ records and tracking their care and experiences. Observations of the homes routines and care provided were made and views on the care provided were sought from people who use the service, visitors and staff. Additionally questionnaires were sent to a random selection of people to ascertain their views. At the time of completion of the report, responses had been received from five people who use the service and four relatives. Their views have been considered as part of the inspection and some comments incorporated within the report. The management of residents’ medication was checked through reviewing prescribed medication for a sample of people. A sample of staff files were reviewed to check the adequacy of the recruitment procedures in protecting people who use the service. The manager, three staff and three people who use the service were also asked specific questions about safeguarding procedures to check the arrangements in place for safeguarding people. St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 6 Communal areas and a sample of bedrooms were viewed and observations were made of people’s general well being, daily routines and interactions between staff and people who use the service. Verbal feedback was given to the Acting Manager on the day of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Improvements to staff practice in relation to the management and recording of medication are needed to ensure that people’s prescribed medication is always St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 7 available and good records are kept to reduce the risk of medication running out. There was an odour in some parts of the ground floor, which needs to be sourced and eliminated to improve the environment for people who use the service and their visitors. Further training is required to ensure that all staff have the necessary knowledge and skills to meet peoples needs. 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 DS0000017693.V364163.R01.S.doc Version 5.2 Page 8 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 DS0000017693.V364163.R01.S.doc Version 5.2 Page 9 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): 1, 3. Standard 6 is not applicable as intermediate care is not provided, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is provided to help people make decisions about their care and a thorough assessment takes place, which helps to ensure that their needs can be met. EVIDENCE: The annual quality assurance self assessment submitted by the Acting Manager states “We provide comprehensive written information for prospective clients, including statement of purpose and patients guide as well as a brochure and corporate information”. A copy of the statement of purpose and service user guide was available in the foyer. From a brief review of the information it was identified that there is a need to review and update the information supplied. For example there was an St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 10 entry which stated that the Commission for Social Care Inspection (CSCI) would carry out at least one announced inspection. CSCI will now only announce an inspection in rare circumstances. The Acting Manager confirmed that she would forward a revised copy to CSCI on completion. The service user guide stated a copy of the last CSCI inspection report was available on request. Advice was given to include a copy of the report within the service user guide to ensure that the information is easily accessible. Information about the service is important in helping people to make decisions about their care. Five out of six people who use the service that responded in surveys confirmed that they had received enough information to help them make a decision about moving in to St Mary’s. The annual quality assurance self assessment states “All prospective residents undergo a pre-admission assessment to ensure the home can meet any identified need and the placement will be appropriate”. Review of the care file for a recent admission confirmed that a through pre-admission assessment had been carried out before the person was admitted. This is important in ensuring that people’s needs are met. St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 11 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): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are in place to support people’s care and good arrangements are in place to monitor standards of care, however shortfalls in the management of medication need to be addressed to reduce the risk to people. EVIDENCE: Surveys identified that two of three relatives who responded feel that people get the support and care that they need. Of the five residents who responded three said they always get the care they need while two said they usually do. One said the reason they don’t always is because there are not enough staff. Discussion with staff and the Acting Manager confirmed that there have been some staffing difficulties, however they said that the situation is improving and that there is now less need for agency staff. This is important in helping to ensure that people receive consistent care according to their needs. Staffing is discussed in more detail in the staffing section. St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 12 Care plans, which are in place, are in most cases comprehensive and appear reflective of people’s needs. However advice was given to include more information to guide staff in meeting the needs of someone in the advanced stages of dementia. Care plans are important documents that help to guide staff in the actions they need to take to meet the care needs of individuals, helping to ensure that people receive appropriate and consistent care. Appropriate risk assessments are in place, which identify the risk of pressure ulcers, falls and people at nutritional risk. Pressure relieving mattresses were in place for someone identified as being at risk of developing pressure ulcers. Detailed risk assessments are in place for the use of bed rails where they have been assessed as the most appropriate solution to reduce the risk of falls from bed. The risk assessment process helps to minimise the risk to people who use the service. Care records confirm that people’s health care needs are monitored and that relevant health professionals are contacted for advice and to visit as necessary. A General Practitioner spoken with during the inspection confirmed that they had no concerns about how people were cared for and that appropriate referrals are made to them. A sample check of the management of people’s medication confirmed that appropriate systems are in place for the management of medication. However notifications received, review of an audit carried out by the quality and compliance manager on 22nd April 2008 and the findings of this inspection identify some ongoing concerns about staff practice. The sample check of medication carried out by the quality and compliance manager was thorough and clearly identified shortfalls. These included lack of an effective audit trail, medication not administered and medication with a short shelf life without dates of opening. Investigations are being carried out in to the discrepancies, however some similar discrepancies were found during the inspection indicating the need for ongoing monitoring of staff practice and competence. A sample check of medication received and medication signed as being administered balanced with medication in stock. However it was not possible to easily check this in one case, as medication carried forward from the previous cycle had not been recorded. It is important that there is a clear audit trail in place as this helps to quickly identity discrepancies and also helps to identify when stocks are running low. It was found that there was no stock of one prescribed medication for someone and records showed that this had not been available for three days. St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 13 Clear records were in place for controlled drugs, which were stored appropriately and records corresponded with stocks held. Dates of opening were not consistently recorded on medication with a short shelf life. Advice was given to do this to ensure that the medication administered remains effective. Observations and discussion with people during the inspection confirmed that people are treated with dignity and respect. Personal care was provided in the privacy of people’s rooms and people requiring assistance with personal care were clean and well presented. St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 14 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): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are provided, contact with friends and families is encouraged and people are generally satisfied with the meals. EVIDENCE: Care records show that information is gathered about people’s preferred routines and rituals helping to ensure that preferences can be met. Surveys received from three relatives identified that they felt that the different needs of people are met. People who use the service and relatives spoken with during the inspection confirmed that visiting arrangements are flexible and that family and friends are encouraged to visit. Observations in the dining room at lunch time identified that people were relaxed and supported with their meals and that they had a choice of food. The meal was well presented and cooks liaised with care staff about special St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 15 requirements and needs helping to ensure that people’s needs and preferences were met. Discussion with catering staff identified that they cater for special diets such as soft and liquidised foods, diabetic diets and diets which take account of people’s religious needs. However discussion identified that they were not aware of advice given from the dietician in respect of a particular person who uses the service who required additional butter and cream added to their diet. This identified the need for closer links between nursing staff and catering staff to ensure that all individual dietary needs are met. A relative said that the food always looked appetising. Comments from people who use the service received in surveys and during the inspection identified that people were either always or usually happy with the meals provided. There is an activity room and a plan of activities, which includes some external entertainers. A bar was being built in the activity room to try and create a more social environment. The activity organiser said that each morning she tells people what is going on that day and asks if they want to join in. Ideas for activities are discussed at meetings with people who use the service. Of the five people who responded in surveys, two said there were always activities that they can take part in, one said there usually were and two said sometimes. Activities are an important part of people’s day and provide social and mental stimulation. St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 16 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): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are procedures for dealing with concerns and complaints, which people are aware of and staff are aware of their responsibilities for safeguarding the people in their care. EVIDENCE: Information about how to make a complaint is displayed throughout the home. Contact details for the regional director are included which provides people with the opportunity to speak with someone outside St Mary’s. Discussion with people who use the service confirmed that they know who to talk to if they have a concern. The annual quality assurance self assessment (AQAA) identifies that five complaints have been received in the last twelve months, three of these were upheld. The AQAA also identifies that within the last twelve months there has been a high number of referrals made to social services through the safeguarding adults procedures. Notifications received by the Commission for Social Care Inspection identify that these have indicated poor care. This inspection indicates that improvements have been made to the standards of care provided and the Acting Manager advised that no complaints have been received recently. St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 17 The AQAA, training records and discussion with staff confirm that some staff have received training in safeguarding and that more training is planned for those staff that haven’t yet received it. Staff spoken with were clear about their responsibilities in relation to safeguarding vulnerable people in their care and were aware of the procedures for reporting any concerns. People who use the service and spoken with during the inspection confirmed that they felt safe and were happy with how they were treated by staff. St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 18 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): 19, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is clean, comfortable and in good decorative order. However the malodours in some areas are unpleasant. EVIDENCE: There is no specific refurbishment plan in place, however there was evidence as rooms become empty they are repainted and refurbished as necessary. People’s rooms were well presented and personalised. Communal areas are homely and efforts have been made to provide a pleasant environment with the addition of pictures and flowers throughout. People spoken with during the inspection were generally happy with their environment and one commented that their room was kept “very nice”. St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 19 Responses from people who use the service in surveys include two who feel that the home is always fresh and clean, two say usually and one sometimes. A sample check of the environment during the inspection identified that it appeared clean and tidy however there were some malodours in some parts including the foyer. A survey received from someone who uses the service refers to there being a malodour on the ground floor. The AQAA identifies that only four staff have currently received training in infection control. This training is important in helping to reduce the risk of infection. Information received in the annual quality assurance self assessment and a sample check of maintenance records during the inspection confirmed that equipment is serviced regularly helping to maintain a safe environment for people who use the service. St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 20 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): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are being made to the staffing arrangements, however staffing levels need to be monitored and further training provided to help ensure that peoples needs are fully met. EVIDENCE: Relatives and people who use the service spoken with during the inspection were happy with the staff that provide the care. Comments included “staff are friendly”, “staff are friendly”, “staff are so caring”. Information received in surveys indicates that although people are happy with the staff team they feel there are not always enough staff available. The Acting Manager acknowledged that there had been some staffing difficulties and that it had been necessary to use agency staff to cover the shortfall, however felt with the recent recruitment that this was reducing. There was one member of staff short on the day of inspection and staff were observed to be working hard to minimise the impact on people who use the service. St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 21 On the day of inspection ten new staff were attending induction training and more staff were due to start the following week. The increase in permanent staff is likely to improve the consistency of care. However it is important that staffing levels are closely monitored to ensure that they are sufficient t meet the needs of people who use the service. The number of staff with a basic care qualification is very low. Only five of the forty five permanent care staff have achieved a National Vocational Qualification (NVQ) at level 2 or an equivalent qualification. It is recommended that at least fifty percent of the staff team have a qualification as it helps to give them a basic understanding of care practices and the needs of older people. Discussion with staff identified that they are however receiving some in house training on care practices and one of the nurses spoken with confirmed that she had received tissue viability and wound care training. The annual quality assurance self assessment (AQAA) acknowledges that more training is needed to ensure that all staff have received appropriate training. There was some evidence that this is starting to be addressed and fire safety training was being carried out on the day of inspection. The annual quality assurance self assessment submitted on 19/03/2008 states: “We perform appropriate CRB, PoVA and NMC PIN checks for staff”. Review of three staff files confirmed that the above checks are carried out as part of the recruitment process. Two references had been obtained for all three staff, however advice was given about the need to ensure that the employer had provided references. One of the references for one member of staff had been provided by a friend who was a manager rather than one being obtained from the care home she had previously worked in. St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 22 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): 33, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The quality assurance systems help to protect the health, safety and welfare of people who use the service. EVIDENCE: Standard 31 relates specifically to the registered manager and their experience and qualifications. There is no registered manager in post, however the management arrangements are commented on as they are considered to be a key factor in helping to ensure that residents receive appropriate care. St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 23 At the time of the inspection there was an Acting Manager who had been in post for three months. She advised that an application for registration has recently been submitted to the Commission for Social Care Inspection. The last full inspection was carried out in April 2007 and no major concerns were identified. However later in the year, serious concerns about standards of care at St Mary’s were raised, which resulted in safeguarding investigations and multi agency ‘serious concern’ meetings. As a result of the concerns a block on placements was agreed between St Mary’s and social services and the primary care trust between September 2007 and February 2008. The findings of this inspection indicate that there have been improvements in standards of care since that time. The fall in standards, which appears to have occurred following the inspection in April 2007, highlights the need for the organisation to have robust quality assurance process in place. Review of the processes showed that they include monthly visits by a quality and compliance manager to check standards of care provided to people who use the service. Review of the report of a recent visit confirmed that these visits are thorough; identify any shortfalls and detail actions to be taken to address. They also focus on issues that directly affect outcomes for people who use the service. Surveys were sent out to people who use the service at the end of 2007 and the responses were collated. This indicated that there has been an improvement in the level of satisfaction with the service. The Acting Manager advised that staff have been informed of the feedback; an action plan has been developed. It is planned to share this information with people who use the service at the next meeting with them. Money is held on behalf of some people who use the service to assist with paying for services such as hairdressing and chiropody. There is a policy in place for the management of people’s money and clear records are kept with receipts to verify transactions. A sample check confirmed that people’s money is well managed. St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 24 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score N/A X 3 X 3 X X 3 St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 25 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. Standard OP9 Regulation 17 (1) (a) Requirement Quantities of medication carried forward to the new cycle must be recorded to ensure there is a clear audit trail which helps in identifying any discrepancies or shortfalls. This will reduce the risk to people who use the service. People’s prescribed medication must be available and administered as prescribed. All staff must receive training appropriate to their role. Timescale for action 30/06/08 2. 2. OP9 OP28 OP30 13 (2) 18 (1) (c) (i) 30/06/08 30/08/08 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. Refer to Standard OP1 OP1 Good Practice Recommendations The statement of purpose and service user guide should be reviewed to ensure that all information is current. A copy of the most recent inspection report should be made available with the service user guide to ensure that DS0000017693.V364163.R01.S.doc Version 5.2 Page 26 St Marys Nursing Home 3. 4. 5. 6. OP15 OP26 OP27 OP29 the information is easily accessible. Catering staff should be kept informed of recommendations made by dieticians to help ensure that people’s dietary needs are fully met. The source of the malodour on the ground floor should be investigated and steps taken to eliminate it. Staffing levels should be kept under review through discussion with people who use the service to ensure that their needs are being met. Care should be taken to ensure that references for staff have come from the employer. St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. Extracts may not be used or reproduced without the express permission of CSCI St Marys Nursing Home DS0000017693.V364163.R01.S.doc Version 5.2 Page 28 - 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. 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