Inspection on 15/08/06 for St Michael`s Care Home

This inspection was carried out on 15th August 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Michael`s Care Home 26/07/07

St Michael`s Care Home 02/03/06

St Michael`s Care Home 11/08/05

St Michael`s Care Home 24/11/04

St Michael`s Care Home 20/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE St Michael`s Care Home Marine Parade East Clacton on Sea Essex CO15 6JW Lead Inspector Lysette Butler Unannounced Inspection 08:30 15 August 2006 th 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 Michael`s Care Home DS0000015327.V309964.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 Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Michael`s Care Home Address Marine Parade East Clacton on Sea Essex CO15 6JW 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) 01255 423688 01255 423594 The Sisters of Mercy of the Union of Great Britain Mrs Angela Pearl Barton Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39), Physical disability (1) of places St Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 39 persons) One person under the age of 65 years who requires care by reason of a physical disability, whose name was made known to the Commission in July 2006 2nd March 2006 Date of last inspection Brief Description of the Service: St Michaels provides residential care for 39 older people. The home is situated on the sea front at Clacton on Sea and is close to local shops and amenities. The building is a large property spread over three floors. There is a religious community adjacent to the home and a Chapel that is shared by the home, Convent and the local community. There are gardens and terrace areas around the property with views over the sea. There is an attached car park for visitors plus ample roadside parking nearby. Current fees are between £385 to £450. St Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection started on 1st April 2006. The inspection process included: a site visit on 15th August 2006, which lasted 71/2 hours; review of evidence supplied by the proprietor, residents, visitors to the service and the staff; resident, visitor, healthcare professionals and staff surveys; discussions with the registered manager, senior carers, care staff, ancillary staff, residents and relatives. During the site visit the premises were inspected, including inspection of the grounds. Samples of records and residents care plans were also reviewed. The home was clean, tidy, airy and well maintained. The overall care and well being of the residents was the focus of the inspection. Staff and residents were welcoming and happy to speak to the inspector at the site visit. The manager and her staff approached the inspection in a positive and cooperative manner that was focused on achieving best practice to meet the needs of the residents. What the service does well: What has improved since the last inspection? Pharmacy procedures and medication storage has improved, the staff find using the multi dose system and easier way to administer the medications safely. All medications are now in one place and properly stored. Infection control procedures have been tightened with the use of different coloured mops and buckets; paper towels and soap dispensers being fitted at all sinks; and the use of hand rub by the staff in some areas. The manager has been registered with the Commission for Social Care Inspection and is clear on what is needed to continue the improvement in his home. St Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Michael`s Care Home DS0000015327.V309964.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 Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. Prospective residents and their families are given both written and verbal information that allows them to make an informed decision as to whether St Michaels is the right place for them to reside. EVIDENCE: A statement of purpose supplied at the time of the site visit had been reviewed and updated in June 2006 by the new manager. It was clear, detailed and contained all elements required by this standard. The document states that it will be reviewed on a six monthly basis or sooner if circumstances dictate. There is a service users guide kept in the library for everyone to access, but the new manager is anxious to ensure that all residents have their own copy of the guide and is intending to review/update it in the near future and give them all a copy. St Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 9 All assessments of prospective residents are completed following the receipt of social services assessment (COM5) and completion of the homes own assessment documentation. The manager and inspector discussed the documentation, which is rather brief, the manager currently adds the information she needs on separate sheets, however this is another document that she intends to review and expand in the near future. On the three care plans there was evidence of brief assessments being made before the residents were admitted. However there is no evidence throughout the home that there have been any inappropriate admissions. Respite care is offered at this home, but intermediate care is not. St Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. The health and personal care offered by this home to the residents is excellent, however documentation needs to be improved to ensure continuity of care. EVIDENCE: Three care plans were reviewed during the site visit. Although there is a lot of detail included in them, it was difficult to follow an audit trail as the information was spread over two or three folders. Each folder contained information about multiple residents rather than all information about one resident being in an individual file. (Although each piece of information referring to each resident was in different plastic pockets so that there was no confusing whose information was whose.) The manager and inspector discussed the layout and usability of the care plans at length. The manager has worked with care plans for a number of years and is clear on what needs to be done to bring the plans up to standard. New typed care plans were being compiled for all residents at the time of this visit, however one of these St Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 11 was reviewed and the actions contained within it were not the most current, one referencing a change in care that happened in 2004. Daily progress notes were written, however on the three files looked at none had been reviewed monthly since January 2006. The medical care of the residents of this home was looked after by local GPs. The GPs attended the home on a regular basis, or if asked specifically to see individual residents. In the care plans there is evidence that doctors and medical professionals have been to the home, but as mentioned above the information needs to be moved within the individual care plan, file to enable staff to follow what has happened to which individual resident. District nurses attended the home regularly as needed and they took bloods for those residents who had blood-clotting problems. All health care services are offered to the residents mainly within the home, but if they need to go outside the home and family, or friends are not available to escort them, a member of the homes staff will go with them. One of the residents spoken to stated that they had had a deterioration of their health about a year before, but the care and kindness of the staff of the home had restored them to health. They also said that the staff obtained medical input from various professionals as soon as it was needed. On the day of the site visit one of the GPs attended the home as did the regular chiropodist. Since the last inspection the home has changed over to the monitored dosage system (MDS) of medication administration, but the home are about to go through another change to a different pharmacy, which they hoped would improve the supply of medication as needed. The new providers were attending the home the day after the site visit to train the staff with their systems. The staff spoken to who administer medication said that the MDS system is reasonably easy to use although the initial supply of medications needed to be better, which they were hoping would happen with the new supplier. All medications and trolleys had been moved into a separate room containing an air-conditioning unit to maintain temperatures at the correct levels. However temperatures were not being taken and documented on a daily basis, which would ensure that the air-conditioning unit was working correctly. There was a signature list in the front of the file containing the administration records; a picture of each resident was kept on the MDS file rather than the administration file. There were no controlled drugs in the home at the time of the site visit although one resident was on Temazepam, which was kept in the controlled drugs cupboard. The stock levels throughout the home were good and all equipment used for administration of medications were clean and well cared for. Pill cutters were seen at the time of the site St Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 12 visit had no residue on and the inspector was told that it was cleaned after each use. There were a number of discontinued medications on administration records, on discussion it appeared to be medications that were still on the prescription when sent to the pharmacy and neither the pharmacy nor the GP surgery had removed them. However staff need to sign and date if the medication is discontinued during the month and must ensure that they are removed from a prescription. Lack of signatures or clear instructions were also noted on the medication charts of the residents who were either fully or partially self-medicating. Privacy and dignity throughout the home was maintained to a very high level. Residents spoken to felt safe and respected within the home. Every resident or visitor spoken to said that staff were kind, caring and hard-working. The residents were clean and well groomed. Some of the nuns continued to wear their habit others did not, however all the nuns were called sister and their religious name as was their choice. All other residents were addressed in the form that they had asked for. It was evident on care plans that the majority of the residents of this home have made clear wishes known about what to do in the event of their health deteriorating or their death. All of the nuns in the home were primarily under the care of the convent as regards as their religious and life needs, including the arrangements for their deteriorating health and funerals. St Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. The residents of this home had choice about their daily life and social activities. The feeling of community is excellent and residents of really appreciate the care and facilities offered. EVIDENCE: As this home is part of the local convent the daily activities mainly revolve around the various services and prayers. There is a mass at 09.30 every morning and various other prayer times throughout the day, which are open to the nuns of the convent and care home, the other residents of the home and the local community. The relationship with the local community is excellent because of this and the residents who were not Roman Catholic told the inspector that they never felt, or were made to feel as if they should be joining any of the religious services. The non Roman Catholic residents of the home also said that they were happy with the activities offered in between prayers and did not feel that the religious side of the home made them loose out in anyway. Following Mass every morning the majority of the residents meet in an area next to the dining room, where they have coffee and biscuits and chat. This appeared to be the focal point of the day for many of the residents and St Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 14 staff alike, it helped to give the home its happy, ‘community feel’. The manager occasionally attended mass which the residents were particularly pleased about. Shortly before the site visit the nun who had undertaken many of the activities within the home had unfortunately moved on, the manager was in the process of recruiting activities staff to take over this role, however there was still regular exercise sessions carried out by an outside fitness leader. A local craft group attended the home once a week and sat with the residents to help them with knitting, crochet and various other craft activities. The home also owns a minibus, which was in regular use. Numerous outings were arranged; most recently during the hot weather there had been a number of visits to beach huts along the Clacton, Frinton, Holland coastline, which all of the residents spoken to had thoroughly enjoyed. The local branch of Age Concern had supplied the home with a computer, which was in constant use, the manager commented that they often had to have a rota system for its use. One resident spoken to said that it enabled them to keep in contact with all their friends both nationally and worldwide; they thought that there should be at least two other computers in the home, as they often had to book time on it, particularly for the Internet. There is also a separate games room which has a lovely view out to sea, where residents can do puzzles, play board games or cards as they wish. At the time of the site visit there were 33 residents, 23 of whom were Roman Catholic, the remaining 10 of were of other religious denominations. The home is in the grounds of the convent and there is a large linking chapel. There are no longer any nuns on the staff of the home, however the nuns that still reside in the convent regularly visit the home to speak to the residents and join in activities. There is a definite ‘community feel’, where everybody mixes and the local community outside of the convent are very welcome. There are no restrictions on visiting and there are plenty of areas to sit with visitors either in private or in a bigger group. All residents were on the electoral register at the time of the site visit. At the last election some voted at the polling stations and others had postal votes, it was the residents choice as to how and if they wish to vote. The kitchens at this home catered for the nuns in the convent and the residents of the home. The nuns who still reside in the convent had their own dining refectory separate from the dining room of the care home. The kitchens were large and clean but rather old-fashioned in style. The environmental health officer had been within the previous year and was happy with the kitchens as they were. However there are future plans to refurbish the kitchen including replacement all of cupboards with open stainless steel shelving as is St Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 15 the present requirement for communal kitchens. All the residents and visitors spoken to said that the food was of good quality and in large quantities. However information supplied following the site visit through resident surveys highlighted some dissatisfaction with the choice and quality of food offered. This information was passed to the manager for further follow up. The manager was looking into the possibility of getting a serving trolley, so that rather than everything being put on a plate and served, residents could have portion sizes to their own requirements. Residents had a choice of food at each meal and at least one fresh vegetable was served daily. Breakfast was served at various times to suit the residents choice, although all those who were attend Mass were given breakfast early enough to allow them to do this. There is a separate dining room staff that helped serve the food, but on the day of the site visit there was no residents who required feeding. Care staff were observed communicating well with the residents during this time. During the site visit one resident returned from hospital and the kitchen staff made them an omelette as requested by the resident. There was evidence of jugs of fluid and glasses throughout the home and within reach of all chair/ bed bound residents. St Michael`s Care Home DS0000015327.V309964.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 17 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. Policies & procedures in this home ensure the safety of the residents and staff are aware of their responsibilities under POVA. EVIDENCE: There have been no complaints to the home, or to the Commission for Social Care Inspection since the last inspection. All staff have had POVA training and some were booked on a course the week following the site visit, to keep them updated. All staff were given the POVA booklet and staff spoken to demonstrated an understanding of the requirements of POVA. St Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 25 & 26 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. This home and the convent work very well together, to give the residents an environment that is appropriate for the dependency of the current residents. It is safe, well maintained and has a very pleasant atmosphere for all that are resident or visit it. EVIDENCE: There has been no change to the fabric of the building since the last inspection. This home is large and spacious, it was the original convent and there are a number of shared areas as well as individual rooms of varying sizes. There are also religious icons throughout the home in all areas. However visitors and residents spoken to who are not Roman Catholic did not find any of the symbolism a problem. At the time of the site visit the home was light and airy with no unpleasant smells detected. All windows had restrictors fitted, but it was a warm day and many windows were open as far St Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 18 as they could be to allow air to flow through. There was obvious signs of redecoration going on in various parts of the home. Resident rooms were decorated between residents or more often if they required it. All rooms viewed showed high levels of personalisation and the majority of the rooms had views over the sea and surrounding areas. Some rooms had small balconies, which were used by the residents of those rooms. The convent and care home has large spacious grounds and residents are welcome in any part of the grounds. However some areas were uneven and wheelchair users could only access them with help of the care staff. The manager was aware of this and the improvement of these areas is part of an improvement plan for the home. The chapel was large and very light, residents and visitors were welcome in there at any time. There is a resident priest who undertakes all of the services within the chapel. This home has a no smoking policy and at present does not have any residents that smoke. There were numerous shared areas throughout the home of various sizes. All areas were used for a variety of all of activities at different times of the day. Throughout the site visit the inspector observed small groups of residents chatting with each other and generally enjoying their time there. A new call bell system was in the process of being installed at the time of the site visit, but until it is fully functioning every resident still has access to a way of communicating if they need to speak to staff. The home has three hoists, one quite new, which has been in regular use since it arrived. In this home the bedrooms are of varying sizes and shapes, some are en suite. It was noted at the site visit that two rooms had lino floor covering, however both residents had been asked if they wished to have carpets fitted and both had declined. There were four rooms near the chapel, which were quite cut off from the rest of the home. The manager is discussing these rooms with the trustees, but the residents currently in them are very happy to be that close to the chapel and are comfortable. The laundry is large and spacious, well laid out, tidy and clean. It is well placed within the home and there is a separate sluicing area for use as needed. Soiled laundry is put into red bags that disintegrate in the washing machine so there is no need to empty and handle the leaning by the laundry staff. Since the last inspection there has been an increase in the number of infection control procedures. There are now different coloured buckets and mops for each of the areas of the home, so that there is no cross contamination. And it was also noted that there were new soap dispensers and paper towel St Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 19 dispensers next to all sinks throughout the home and staff were observed to be using these frequently. St Michael`s Care Home DS0000015327.V309964.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. Staff skill mix and levels of training insured that the needs of the residents were met within this home. EVIDENCE: Staff rosters reviewed before and during the site visit demonstrated staffing numbers and skill mix appropriate to the level of dependency and number of residents of this home. Although the layout of the home would suggest that higher numbers of staff would be beneficial in times of full occupancy. The manager normally worked Monday to Friday and would undertake early shifts if necessary and also to undertake supervision duties as needed. Staff turnover at this home is normally very low there had been two resignations of senior staff for personal reasons during the inspection process, but the manager was already in the process of interviewing and employing replacements. One member of staff spoken to during the site visit had worked at the home for over 20 years was very happy there and loved working at home and couldnt think of leaving completely, even though she had recently reduced her hours. The majority of care assistants at this home had NVQ level 2 or above and four further staff were registered to undertake courses in the autumn. One other person had National Vocational Qualification level four, as well as the manager. St Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 21 The manager is an NVQ assessor and internal verifier, so assisting care assistants through NVQ courses in the future will be further improved. Three recruitment files were reviewed during the site visit, they contained all the necessary elements, however some of the older files had very little information, but these members of staff were employed before the present regulations and the manager had insured that the basic information was available. The manager was planning to tidy all files so that they are userfriendly. One file of a new member of staff who had been employed by this manager was clear and followed all guidelines. No member of staff was employed before there Criminal Records Bureau declaration was returned to the home. The training matrix was up-to-date and everybody on the staff had attended all required statutory training. The manager was in the process of compiling individual training matrices for each member of staff. St Michael`s Care Home DS0000015327.V309964.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 37 & 38 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. The overall management of this home is good and residents benefit from the procedures followed by the management team and the staff in the home. EVIDENCE: Since the last inspection the new manager has been registered with the CSCI. She has worked as a care home manager for a number of years and has also been an NVQ assessor and internal verifier. She already has the registered managers award and NVQ level 4 in care and the Registered Managers Award. The manager was friendly and open during all aspects of the inspection process. She stated that she felt very supported by the convent and trustees of the home. She demonstrated a good understanding of her role and the needs of the residents of this home. St Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 23 The ethos in this home was excellent throughout staff, residents and visitors to the home all spoke of the interest of the manager and the level of care offered. Everyone was welcoming during the site visit and in a number of cases requested to speak to the inspector to express their positive views of the home. During the site visit the residents were concerned on behalf of the manager that everything on the inspection was going well. The most recent survey carried out by the home was undertaken in January. The manager is aware of the need for a quality assurance plan for auditing a number of aspects of the care offered at the home. During the site visit survey forms were given to all service users and their relatives, and number were returned before this report was written expressed positive feedback. A number of the residents at this home looked after their own financial affairs and the convent looked after the financial affairs of all the resident nuns. The homes administrator only looked after the accounts for five residents. All five accounts were checked and were correct. Records and invoices kept of all the accounts were detailed and easy to follow. All invoices were paid from the homes petty cash and then the administrator invoiced either the residents directly, or replaced the money from the five accounts that she held and put the invoices in the pouch’s used to hold the money and invoices. The documentation of the accounts was kept in an A4 book and the administrator was advised to use a loose-leaf folder instead so that the records can be properly archived with the individual residents notes. The manager kept a matrix of supervision required and appraisal due dates. All supervisions and appraisals were up-to-date at the time of the site visit. The manager had discussed the mix of group and individual supervision sessions with the inspector. All policies and procedures were kept in the managers office and staff were aware that they were there. However they all needed review, the manager was aware of this but has not felt this was a priority as there were so many other things needed following up in the home during her first six months. None of the policies and procedures review were very out of date and would probably only need checking. All certificates and servicing contracts seen during the site visit were up-todate and were extensive. Regular maintenance records were complete and well maintained. St Michael`s Care Home DS0000015327.V309964.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 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 3 3 X X X X 3 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 4 2 X 3 X 2 3 St Michael`s Care Home DS0000015327.V309964.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 OP7 Regulation 15(2b-c), Schedule 3(1b) 15, Schedule 3(1b), 13(4b-c) 24(1-3) Requirement The registered person must ensure that all care plans are reviewed regularly. (This will normally be once a month.) The registered person must ensure that all care plans are up to date and only contain information regarding the residents’ current needs. The registered person must compile a quality assurance plan that ensures there is on-going improvement in the care offered to the residents. Timescale for action 30/09/06 2 OP7 31/10/06 3 OP33 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP9 Good Practice Recommendations The registered manager should ensure of that all information about individual residents are kept in one individual named file. The registered manager should ensure that the DS0000015327.V309964.R01.S.doc Version 5.2 Page 26 St Michael`s Care Home 3 4 5 OP9 OP9 OP37 medication room temperature is taking each day and documented. The registered manager should ensure that all discontinued medications are signed and dated by the person changing the medication administration records. The registered manager should ensure that all medications given to residents for safekeeping are signed for. The registered manager should ensure that all policies & procedures are reviewed annually. St Michael`s Care Home DS0000015327.V309964.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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