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Inspection on 09/08/07 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 9th August 2007.

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

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

Records were kept as required by regulation and those seen were up to date. Residents said they enjoyed their meals and were given a choice of meal. Visitors seen said they were made feel welcome and staff communicated appropriately with them. Residents were satisfied with the meals provided and were offered a choice at mealtimes.

What has improved since the last inspection?

A risk assessment was completed for all residents prior to fitting bedrails. Improvements were made to medicine management. Some areas of the property had been redecorated. Carpets were clean and the home adequately maintained. Efforts had been made to verify the authenticity of references received for prospective employees.

What the care home could do better:

Residents assessed as being at risk of developing pressure sores must have a care plan prepared to show how the risk will be managed and how pressure area care will be provided. Correction fluid must not be used on care records. Staff must have access to training on the safe management of medicines.The property must be adequately decorated internally and kept clean at all times. The areas identified as requiring attention must be addressed. Staff must have access to training relevant to their work and evidence provided to show this occurs. Suitably trained people must provide staff training. Risk assessments must be kept up to date, include adequate guidance for staff on how to move & handle the person and reflect the resident`s current needs. A system must be in place to follow up unexplained injuries to residents and injuries sustained by residents when they receive care or support and to action taken to prevent a recurrence. This report includes some recommendations for the registered person`s consideration.

CARE HOMES FOR OLDER PEOPLE St Marys Nursing Home 327 Main Rd Sidcup London DA14 6QG Lead Inspector Ms Pauline Lambe Unannounced Inspection 9th August 2007 08:45 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 DS0000006772.V335150.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 DS0000006772.V335150.R01.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.V335150.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5th June 2006 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 £550.00 - £580.00. Residents paid privately for personal items, hairdressing and chiropody services. St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this unannounced inspection was completed on 9th August 2007. The manager and staff assisted with the inspection. Fifteen residents were in home and there were five vacancies. The registered provider was in the home for a short period and spent time talking to the inspector. The service was last inspected on the 5th June 2006. 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 the manager and reviewing compliance with previous requirements. Satisfaction surveys were sent to residents and relatives. Feedback on the quality of the service was generally positive. The service was managed satisfactorily and residents and relatives were satisfied with the quality of care provided. What the service does well: What has improved since the last inspection? What they could do better: Residents assessed as being at risk of developing pressure sores must have a care plan prepared to show how the risk will be managed and how pressure area care will be provided. Correction fluid must not be used on care records. Staff must have access to training on the safe management of medicines. St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 6 The property must be adequately decorated internally and kept clean at all times. The areas identified as requiring attention must be addressed. Staff must have access to training relevant to their work and evidence provided to show this occurs. Suitably trained people must provide staff training. Risk assessments must be kept up to date, include adequate guidance for staff on how to move & handle the person and reflect the resident’s current needs. A system must be in place to follow up unexplained injuries to residents and injuries sustained by residents when they receive care or support and to action taken to prevent a recurrence. This report includes some recommendations for the registered person’s consideration. 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.V335150.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 4. Standard 6 did 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. Systems were in place to assess resident needs prior to admission and to confirm that the home could meet assessed needs. EVIDENCE: No changes had been made to the statement of purpose or service user guide since the last inspection. Care records seen included copies of pre-admission assessments and some included care manager assessments. Residents received written confirmation that based on assessment the home was suited to meeting their needs. Residents were provided with contracts for service and a record made of the suitability of the service to meet residents assessed needs. A number of residents had dementia and some had been admitted with this diagnosis. However the residents in question did require a high level of physical nursing care. The manager provided dementia training for staff but this was not St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 9 considered adequate as she did not have a mental health qualification. This issue was discussed with the manager and the need to ensure staff had access to dementia care training by an appropriate trainer. (Please see comments under standard 30 regarding training.). Recommendation 1. St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 – 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans seen showed how resident care needs including healthcare needs were to be met. Medicines were satisfactorily managed. Residents were satisfied with how staff respected their privacy and dignity. EVIDENCE: Records for two residents were viewed and included care plans, risk assessments, were kept under review and reflected the needs of the residents. Risk assessments were completed prior to fitting bedrails for resident safety. Care plans were generally well written and included details as to how assessed needs were to be met. Risk assessments were completed in relation to identifying residents at risk of developing pressure sores but care plans did not contain adequate information in relation to prevention of pressure sores or pressure area care. It was evident on some records viewed that care plans were discussed with residents and or relatives. There was also evidence to show that the manager had undertaken care record audits. Some records seen had entries corrected using correction fluid. This issue was raised at the last St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 11 inspection. Feedback received from residents and relatives indicated they were satisfied with the quality of care provided. Requirement 1. All residents were registered with a local GP. The GP was seen briefly and said he visited the home weekly and saw every resident. He had a good working relationship with staff and residents spoken with confirmed the GP visited them weekly. Records seen showed residents were supported to access other healthcare professionals such as a dentist, chiropodist and optician routinely. Specialist health such as dietician advice and advice on tissue viability were accessed through referral. Medicine management policies and procedures had not been changed since the last inspection. Boots supplied medicines in a monitored dose system, which staff said they found easy to manage. Medicines were safely stored, and records were kept for receipt, administration and disposed of medicines. A medicine trolley was provided to use when administering medicines. Records enabled an audit trail to be completed for medicines brought into the home. Administration records were well kept and medicines checked for two residents were found to be correct. Homely remedies were supplied and consent to administer these was obtained from the GP. Homely remedy stocks were checked and found to be correct. There was evidence to show that the manager had undertaken medicine audits. No staff training had been provided in relation to medicine management and safety for some time. A discussion took place with the manager regarding the need to introduce a medicine profile for each resident, to have evidence that individual residents had their medicines reviewed by the GP regularly and that staff were assessed annually as being competent to administer and manage medicines safely. Requirement 2 and recommendation 2. Residents who spoke to the inspector or completed feedback surveys indicated staff treated them with respect. Relatives seen during the inspection and those who completed feedback surveys were satisfied with the way residents were cared for. One resident said “staff are very nice and come when needed” and one relative said they felt the home was “fantastic”. Shared bedrooms had screening provided to ensure privacy for the occupants. During the inspection staff were observed interacting appropriately with residents and being responsive to resident’s requests for assistance. Some shared rooms were being used for single occupancy. St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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 spoken with said they preferred to spend their time in their bedrooms and did not like to sit in the lounge or take part in organised activities. Other residents were quite frail and some unable to participate with activities. The service did not have a designated activity organiser and care staff organised activities in the afternoons as part of their role. A system was in place to record the activities provided and who took part in these. Records seen showed that one activity took place almost every day. During the inspection residents were seen enjoying a game of bingo and relatives seen said they had observed activities taking place when they visited. Religious services were provided fortnightly. Social care plans were seen on the care records viewed. St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 13 The home had an open visiting policy and residents who could comment said they were happy to see their visitors in their bedroom or the communal lounge. One relative commented that “the home is not big and staff are like family”. Feedback from residents and relatives indicated they were satisfied with the visiting arrangements and relatives seen said they could visit whenever they liked and were made feel welcome. 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 cooker hood would benefit from a deep clean. The manager said that the kitchen was deep cleaned by staff but there was no record of this. Adequate supplies of fresh and dried foods were seen. The freezer had been emptied for defrosting and the cook said that once this was done the freezer would be restocked. A cleaning schedule was in place and records kept of fridge, freezer and food temperatures. All of these records seen were 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. Although various cereals and cooked foods were available none of the residents in the lounge were offered a choice and all of them were given porridge, which they were observed to readily eat. Residents having breakfast in their bedrooms were seen to have other cereals provided. During lunch staff were observed being attentive to residents and assisting them sensitively as needed. Meals were covered when being served and were not served to residents requiring assistance until staff were ready to assist them. 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 and where indicated they were referred to the GP or dietician for advice. A number of residents were having additional food supplements. Recommendation 3. St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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 to ensure complaints and safeguarding adult issues were managed appropriately. Residents and relatives indicated they knew who to talk to if they had a concern. EVIDENCE: A complaints policy and procedure was provided, included in the service information and displayed in the entrance hall. Residents and relatives were aware that if they had a problem they would talk to the manager. Records were kept of complaints made about the service. Since the last inspection no complaints had been made about the service to the registered person or the Commission. Residents who spoke to the inspector indicated they knew who to talk to if they had a concern. Feedback from relatives indicated they knew about the home’s complaint procedure. Allegations or suspicions of abuse were referred to Bexley Social Services for investigation. Copies of the Bexley Safeguarding Adults Procedures, ‘alerter’s’ guide and a copy of the DOH document ‘No Secrets’ were provided. Staff who spoke to the inspector displayed an understanding of adult protection and how they would manage such an incident. Since the last inspection the local authority investigated one allegation of abuse. The outcome of the investigation was not known when writing this report. The St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 15 manager said that staff had access to training on safeguarding adults from the local authority. St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment was showing signs of wear and tear and the registered person said plans were being prepared to upgrade and refurbish the home. In the meantime issues with decoration and hygiene must be addressed. Residents and relatives did not raise concerns about the environment. EVIDENCE: From a tour of the premises and maintenance records seen the home was safely maintained. Although the environment did not pose a risk to residents the internal décor was showing signs of age and wear and tear. Since the last inspection some redecoration work had been undertaken. The manager said that this included the first floor landing, some bedrooms and some chairs were purchased for relatives to use when visiting residents in the lounge. Areas identified as requiring attention included the corridor on the first floor, bedrooms 3, 15 and 16 and the bathroom on the first floor. Time was spent St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 17 talking to the registered provider who said he planned to upgrade and refurbish the entire home. Plans were currently being prepared, included increasing the number of single rooms and providing en-suite facilities. The provider was aware of the need to inform the Commission of any planned changes to the environment. The rear garden was neat and tidy and accessible to wheelchair users. The exterior of the home was satisfactorily maintained. Requirement 3. Bathrooms and toilets were clean and tidy. The first floor bathroom would benefit from being redecorated. Hot water temperatures checked were within safe limits. Records seen for in-house hot water temperature checks showed these were maintained within safe limits. Up to date service records were seen for the assisted baths. Requirement 3. A number of bedrooms were viewed and some of these required redecoration. Please see comments under standard 19. Some bedrooms were nicely personalised and one resident said they liked being able to bring some of their own items to the home as it made the bedroom more ‘homely’. Screening was provided in shared bedrooms for additional privacy. As mentioned a number of residents could not comment on how satisfied they were with the environment while others did not express dissatisfaction with the environment. The home was tidy, well ventilated and free of offensive odours. However attention was needed to high dusting in bedrooms and other areas, for example the tops of radiators were very dusty. The radiator in the lounge was very dusty and needed deep cleaning. Hand washing facilities were available where waste was handled and staff had access to protective clothing. Requirement 4. St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 – 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Records showed adequate staffing levels were maintained and 50 of care staff had achieved NVQ 2. Some concerns were noted regarding evidence and suitability of staff training. Satisfactory recruitment procedures were in place. 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 the home adhered to staffing levels agreed with the previous regulatory body. Staffing on the day of inspection complied with the home’s staffing notice. Comments made by residents and relatives included “the staff are always most supportive” and “staff are very nice”. Feedback from relatives indicated that in their opinion there was enough staff on duty and comments made included “it is home from home”, “staff are attentive and friendly” and “I am very pleased with the care home in every aspect”. Twelve care assistants were in employment, seven had achieved NVQ level 2 training or above and three staff were working towards this qualification. Four employee files were viewed. These showed that staff had been recruited in line with regulatory requirements. One reference seen had not been verified St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 19 as authentic. A system was in place to check that nurses employed were registered with the Nursing & Midwifery Council. Requirement 5. Staff who spoke to the inspector said they had access to training relevant to their roles. The manager said that she provided some in-house training and arranged external training courses for staff. Evidence to support staff training was poor. Since the last inspection training records seen showed that two care staff had received moving & handling training. Prior to finalising this report evidence was provided to show that 14 members of staff received moving and handling training on 17/5/07. The manager said that other training such as dementia care, wound care and challenging behaviour training was provided but there was no evidence to support this. The dementia care training was provided in-house and may not have been done by a suitably trained person. As a number of residents in the home suffer from dementia staff must have access to training by a suitably trained person. Requirement 6 and recommendation 4. St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is adequate. 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. Unexplained injuries to residents were not investigated and concerns were noted in relation to moving & handling practice. 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. St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 21 Resident and relative meetings were not held but the manager said she and staff communicated with relatives on a one-to-one basis. A number of residents were not be able to voice their views at a residents meeting but others had this ability. Regulation 26 reports were sent to Commission as required by regulation and in-house audits were completed on areas such as care records, medicines and accidents. Since the last inspection the manager had sent satisfaction questionnaires to residents and relatives and planned to collate these into a report and based on findings implement an action plan for improvement. Once this report was completed a copy of the report and any improvement plan must be made available to residents and others and a copy sent to the Commission. At the time of writing this report a copy of the service review was sent to the Commission. Nobody in the home acted as an appointee for a resident. Staff only managed personal allowances for a few residents in relation to hairdressing and chiropody care. Relatives provided money and receipts were provided for money received and spent. Personal finance records were made available to relatives and residents as needed. Adequate records were kept to show how resident finances were managed. From the information provided in the pre-inspection questionnaire 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. 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 forms seen were completed satisfactorily. There was no evidence to show that a number of unexplained injuries or injuries sustained by residents when receiving care and support were followed up or satisfactorily investigated. The manager completed a monthly accident audit, which covered areas such as the resident’s name, date and type of accident. Care staff were observed moving immobile residents using underarm support. The moving & handling risk assessments seen did not provide adequate guidance to show how the resident should be moved. For example the assessment for one resident said staff should ‘use the correct technique’ but this was not specified. The concern noted in relation to observed moving & handling practice was discussed with the manager. Requirements 7 and 8. St Marys Nursing Home DS0000006772.V335150.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 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.V335150.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The registered person must ensure residents assessed as being at risk of developing pressure sores have a care plan prepared to show how the risk will be managed and how pressure area care will be provided. Correction fluid must not be used on care records. The registered person must ensure staff have access to training on the safe management of medicines. The registered person must ensure the property is adequately decorated internally. The areas identified as requiring attention must be addressed. The registered person must ensure the property is kept clean at all times. Attention to detail such as high dusting and cleaning of difficult to access areas such as radiators must be addressed. The registered person must ensure references obtained for employees are verified as DS0000006772.V335150.R01.S.doc Timescale for action 14/09/07 2 OP9 13 14/09/07 3 OP19 23 14/09/07 4 OP26 23 14/09/07 5 OP29 19 14/09/07 St Marys Nursing Home Version 5.2 Page 24 6 OP30 18 7 OP38 13 8 OP38 13 genuine. The registered person must 14/09/07 ensure staff have access to training relevant to their work and provide evidence to support this. Suitably trained people must provide staff training. The registered person must 14/09/07 ensure a system is in place to investigate unexplained injuries sustained by residents and action taken to prevent a recurrence. The registered person must 07/09/07 ensure resident’s moving and handling risk assessments are up to date, include adequate guidance for staff on how to move & handle the person and reflect the resident’s current needs. 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 OP4 OP9 Good Practice Recommendations The registered person should ensure residents are not admitted outside the home’s category of registration. The registered person should ensure a medicine profile is provided for each resident, there is evidence to show that individual residents have their medicines reviewed by the GP regularly and that staff competencies are assessed annually in relation to safe management of medicines. The registered person should ensure staff offer residents a choice of foods at mealtime including breakfast. The kitchen and particularly the cooker hood should be deep cleaned regularly and a record kept for completion of this task. The registered person should maintain individual staff training records. DS0000006772.V335150.R01.S.doc Version 5.2 Page 25 3 OP15 4 OP30 St Marys Nursing Home Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 DS0000006772.V335150.R01.S.doc Version 5.2 Page 26 - 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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