Inspection on 02/10/07 for St Michael`s Cheshire Nursing & Residential Home

This inspection was carried out on 2nd October 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Michael`s Cheshire Nursing &... 12/09/06

St Michael`s Cheshire Nursing &... 20/10/05

St Michael`s Cheshire Nursing &... 10/08/05

St Michael`s Cheshire Nursing &... 04/11/04

St Michael`s Cheshire Nursing &... 06/05/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOME ADULTS 18-65 St Michael`s Cheshire Nursing & Residential Home Cheddar Road Axbridge Somerset BS26 2DW Lead Inspector Barbara Ludlow Unannounced Inspection 2nd October 2007 10:00 St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 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 Cheshire Nursing & Residential Home DS0000003291.V353986.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 Adults 18-65. 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 Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Michael`s Cheshire Nursing & Residential Home Cheddar Road Axbridge Somerset BS26 2DW 01934 732358 01934 732809 michaels@lc-uk.org www.leonard-cheshire.org.uk Leonard Cheshire Address 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) Mrs Helen Bond Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (36) of places St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Persons of either sex, in the age range 18-60 years who require nursing care by reason of physical disablement Elderly persons of either sex, not less than 60 years, who require general nursing care Up to twelve places for personal care. Up to 30 places for `nursing care`. Registered for a total of 36 places in Categories OP and PD The home must, at all times, have an appropriately skilled clinical nurse on duty. 13/02/07 Date of last inspection Brief Description of the Service: The home is formed from the conversion of a former TB sanatorium, managed by the Anglican Sisterhood from 1878 until1968. The home now caters for Younger Adults with Physical Disabilities and is managed by The Leonard Cheshire Foundation. The home is set in large grounds on a sloping site that allows access to the grounds from each floor. Many of the original features of the house have been retained. The home is within walking distance of Axbridge Town where there are shops and other local facilities. Accommodation is on three floors. All bedrooms are single occupancy. The home has been well adapted for the younger service user. The home can accommodate self-propelled wheelchair users thereby fostering maximum independence. The grounds are sloping and in parts accessible by wheelchair. There are tables and chairs for use on the patio in the warmer weather. Fees range from: £650.00 to £950.00 (upper level may be more, subject to the assessment of individual care needs) There are two bungalows adjoining the home. These are used as by the Leonard Cheshire Foundation as transitional homes for people. These bungalows are not registered for nursing or personal care. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. The Annual Quality Assurance Assessment (AQAA) was completed and returned to the Commission for Social care Inspection (CSCI). Questionnaires were sent to the home to seek the views of people using the service and their relative’s views. Visiting health care professionals were also sent questionnaires. The outcome of the surveys and comments are incorporated into the inspection report. The inspection visit was made over a seven hour period by two inspectors from the commission. Thirty six people were in residence, this included two people having a respite stay. The Registered Manager, Mrs Helen Bond and the senior clinical nurse were on duty and time was taken during the day to discuss the management of the home. Staff and people who live at the service were seen and spoken with during the day. Daily life throughout the day, which included the serving of lunch, was observed. A tour of the premises was made and records were sampled. This was a very positive inspection and the feedback given was well received. The inspector would like to thank all who contributed to the inspection process on the day and those who returned the questionnaires to CSCI. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: One care plan identified behaviour that is likely to put the service user at risk of harm. This risk had been identified and incidents were documented and staff confirmed they were aware and discussed this at staff handovers. There was no formal risk assessment or strategy for managing this behaviour. This is required at this inspection. A recommendation is made for attention to repair or renew the damaged floor covering in the physiotherapy department staff toilet. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 7 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 Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Quality in this outcome area is good There is a good level of information to allow a prospective service user to make an informed decision about coming to live at St Michael’s Cheshire Home. A pre admission assessment is made to ensure that care needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of purpose was reviewed in May 2007. The statement of purpose also informs the reader of the wider remit of the charitable Leonard Cheshire Organisation, it’s mission statement and core values. The Service user Guide was been updated in May 2007 and now includes pictorial information to make the guide more service user friendly. The service use guide offers information on all aspects of coming into the home for the first time. There had one new admission to the home since the last inspection, periods of respite care had been arranged for others. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 10 People who choose to come and live at the service would be assessed before admission to make sure their needs can be met at the service. Files were sampled and there was evidence of the assessment and information gathering from professionals. This information is used to formulate the start of the care plan on admission. Contracts were sampled and these have been signed since the last inspection. 30 people living at the home responded to the questionnaires returned to CSCI. Twenty five people responding to the question of enough information being available before moving in said that they had received enough to decide it was the right place for them. Comments included ‘my family decided’, ‘I would have liked to look around before I came here’, ‘Always been happy here, no wish to be anywhere else’ and ‘I love living here- people are very kind to everybody here. They cater for all our needs’. Nineteen people said they had received a contract. Contracts had been renewed at the last inspection but had not been signed. Signatures were required on the copies that were held on file, this has now been addressed. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good People are encouraged to participate in the homes social events and activities. Independence, choice and decision-making is supported in all aspects of daily life at St Michael’s. One requirement is made for the formalisation of an identified risk into a risk assessment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Leonard Cheshire organisation ethos promotes independence and choice for its service users. Advocacy and self-advocacy services are promoted and residents have a range of meetings in the home. Residents also form part of interview panels for new staff appointments. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 12 Residents are encouraged to retain management of their own personal finances. Small amounts that are held are recorded, securely stored and safely managed. The home has a small shop that is run by residents in the mornings, on a rota basis and was open at the inspection. Service users spoken with were aware of the organisation’s plans to relocate to an alternative site. See also environment. Risk assessments for individual activities and environmental risks at the home were present in individual care plans. The home is open for residents to move freely in and out of the building to access the grounds. Comments in response to the questionnaire about activities included, ‘I would like to go out more often’, ‘I don’t always want to take part’ ‘I choose not to take part’, ‘I want to be able to go swimming more often than just on holiday’. One person commented that they go out with family and use the homes transport to achieve this. We heard of two people who live at the home preparing to do a ‘parachute jump’, fulfilling an ambition. We met one of the people who said they are looking forward to the challenge and opportunity to take a risk. One care plan identified a behaviour that is likely to put the service user at risk of harm. This risk had been identified and incidents were documented, staff confirmed they were aware and discussed this at staff handovers. There was no formal risk assessment or strategy for managing this behaviour. This is required at this inspection. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good There is a good range of social activity and opportunity for people who live at St Michael’s Cheshire Home. Friends and family are welcomed. The food looks appealing and nutritious and there is a good choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live at the service benefit from having a spacious environment with a choice of communal areas. All areas of the home can be accessed by electric wheelchair, fostering independence for wheelchair users. The home has three minibuses to take people out into the community socially or to meet appointments. There is a shortage of qualified drivers and this is being addressed, the home is advertising for a dedicated driver. This had been recognised at the recent Leonard Cheshire audit of the service at St Michael’s. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 14 One person had commented to the commission that they would ‘like to go out more’. Activities were observed during the day. The communal rooms are well used and there is a choice of areas to use. The top floor of the home now has a coffee bar, which was seen in action during the morning, a range of coffee drinks and toppings were served. The access to the garden from the top floor has been made easier for residents to use. There is an electronic door to the bridge that links the top floor of the home to the sloping grounds. The garden here has been developed to create raised beds for a sensory planting. The corridor adjacent to the bridge exit has been decorated imaginatively by staff to become a sensory area. The home has a thriving computer department where e-mails can be sent and received and computers are used for games and education. All new people have access to a personal email address on admission. Dedicated staffing run this department and they teach the computer skills required on a one to one basis. New technology has been successfully introduced for individuals to use such as communication aids. The top floor of the home also houses the arts and crafts room. A large group of people were seen in the morning and they were involved in various activities including watching television. A staff member who was successfully engaging and developing the social experience for those in the room led the group. There was a relaxed atmosphere and people said they were enjoying themselves. Lunch was observed; the food was nicely presented and served. There was a choice of meals served. Assistance with food where required was given ‘one to one’ in a discreet, unhurried and sensitive way. Drinks were available and there was a good atmosphere and sufficient staff around to provide help as required. Questions relating to the menu received responses such as ‘I can request what I want if I do not like the menu’, ‘food is good’, ‘food is too bland, need more condiments on the table’ and ‘I want a better choice and more cheesecakes’. 7 said they always like the meals, 11 said usually like the meals and 5 said sometimes. Questionnaires on the activities suggested that 11 people always have activities they can take part in, 8 usually have, 5 sometimes have and 1 person said they never do because they don’t want to. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good Care plans are in place for all service users. They are detailed and support the care of people living at the home in a person centred way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were sampled from the thirty six available. There was detailed information about contacts such as the next of kin and family, professionals involved with their care such as the social worker and allied health professionals such as the dentist. Health care checks were recorded such as visits to the dentist, appointments to urology and neurology clinics and clinic for women’s health care checks. Community care reviews had been made under the Single assessment process (SAP) to ensure the placement continues to be suitable and meeting the needs of the service user. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 16 Equipment used to support independent mobility was recorded along with servicing check dates. Risk assessments for items used that could be considered a restraint such as a lap strap in a wheelchair was recorded and consent was noted and signed or witness made on behalf of the service user. Missing person information cards are made up in a laminated format, this was well done. People also have an evacuation plan pertinent to them in the event of the building having to be evacuated. The care service underwent an internal company service audit in August 2007. Some deficits and areas for improvement were identified for the home to rectify. One example of this was re assessment of respite people on re each admission to the service. Social and recreational documentation was described as sparse. There is a lot of social care offered at St Michael’s and we were informed that a new activities coordinator has just been appointed. All interactions between staff and people who live at the service were pleasant and kind. People looked relaxed and at ease with the carers. Medication storage was satisfactory. The management of medications was checked and appeared to be well recorded. Questionnaires asking if the people who live at the home if they receive the care and support they need had a positive response. 14 said always, 9 said usually and 2 said sometimes. In response to do you receive the medical support you need? 19 said always, 5 usually and 1 sometimes. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good Service users are protected from harm at the home by their good recruitment practices; staff training and good care practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes complaints procedure is available in the service user guide. There have been no complaints raised with CSCI since the last inspection. One complaint has been raised at the home pertaining to funding requirements and this is being dealt with. Recruitment practice includes obtaining a criminal record bureau check with a Protection Of Vulnerable Adults (POVA) list check first and two references on all new staff before they commence working at the home. Staff and management have received training on the protection of vulnerable adults and the recognition of abusive practice. The questionnaires indicated that 17 people know how to complain and would feel able to, one person said they would speak to the manager or senior nurse another said they would speak to senior staff. 7 said they did not know how to make a complaint and one person said ‘the complaints procedure needs to be made clearer’. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 18 St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good The home is clean and comfortable. Investment in the premises was evident and is keeping the facilities up to date for the people who live at St Michael’s. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been investment in the premises and there is an on-going routine maintenance and redecoration. The home has a modern laundry facility. There are modern assisted bathing and shower facilities. Bedrooms and bathrooms are in good decorative order. One person commented that the home looks cleaner and fresher having ‘ improved since the corridors were painted’. All accommodation offered is in single rooms. Rooms are personalised reflecting the tastes of occupants. Bedroom doors are not lockable; this is stated in the home’s Service User Guide. There is a lockable facility for valuables provided in each bedroom. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 20 Toilets and bathrooms are lockable and have disabled facilities. There is a range and good choice of shared space. This includes a servery area where residents can get a snack or drink between meals and a new coffee bar. Smokers have their own designated balcony lounge. The home has modern sluice facilities and equipment for staff to manage a good standard of hygiene and minimising the risk of cross infection. Wheelchair access around the home is good. Some service users were seen using the outdoor patio and garden area, which they said, they enjoy. The home was clean and fresh smelling at this inspection. One person had commented that the toilets ‘smell of urine’, the cleaning regime of the home has been changed to provide cleaning in the afternoon as well as the morning. This was done to help to keep the toilets and communal areas clean throughout the day. The Leonard Cheshire organisation still has plans to purchase a new site for the service currently offered at St. Michaels. Residents at St. Michaels are aware of the organisation’s plan to move to an alternative site. The St. Michaels site is large and of character. It has been adapted as far a possible to meet National Minimum Standards but not the environmental standard 24.3 expected by the Commission by April 2007. The manager confirmed that no alternative site has been found and St Michael’s will continue with development and investment for the benefit of the people living there. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 Quality in this outcome area is good There is a skill mixed staff team. Training is provided for staff on a range of subjects to promote good care practice. Recruitment policy and practice is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Roles and staff responsibilities are defined within the staffing structure at the home and are detailed in the Statement of Purpose. The home also uses Community Service Volunteers from across the world. These volunteers are not included in the duty staff rotas; one volunteer from Japan is working at the home at present. There was a sufficient staff team on duty at the inspection to meet the needs of the people in residence. There was staff available at the lunchtime to provide a good level help and support to the people eating together. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 22 The existing staff team or regular agency workers cover any vacant staff shifts. There is a team of administrative, management, physiotherapy, activity and ancillary staff support as well as the care staff and nurses. A new activity organiser has been appointed and starts on 15/10/07. The manager is aware of the increasing dependency levels of people living at the home and is planning to build the staff team to meet these needs through skill mix and an increase numbers. The home has a staff training development officer. The inspectors had time to meet with this member of staff and hear about the work in progress to develop the staff team. The home has a training office and large training room facility. There is a good range of staff training in-house events and staff are enabled to access external training events. The staff training matrix was seen. The National Vocational Qualification (NVQ) Level 2 care award has been achieved or is in progress for all staff for whom it is appropriate to undertake the course. Staff are also studying to achieve this award at level 3. The staff induction programme is linked to the Skills for Care guidance. Staff receive supervision and this is recorded and is signed by both supervisor and supervisee. Staff meetings are held regularly and minutes are produced and circulated to staff around the home. The feedback from people who live at the home indicated that staff are available when they are needed one person commented ‘unless they are busy with someone else’. 20 of the 23 respondents said staff listen and act on what they say. Other comment was ‘I like living here and I find the staff and other residents very friendly’. ‘I am reasonably independent but the staff meet my needs when necessary’. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38, 39,40,41,42,43 Quality in this outcome area is excellent St Michael’s benefits from having an experienced and skilled management team and the policy and staff support of the Leonard Cheshire foundation’s networks. The home is run for the service users, their best interests being paramount. Quality is measured and improvements continue to be made. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a competent and experienced manager. Mrs Bond is supported by a management and staff team that are very professional in their work. One service user spoken with felt the home had improved because of the leadership of Mrs Bond and her management team. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 24 The home has adopted all Leonard Cheshire policies and procedures and codes of practice. The Disability Forum endorses these. These documents are updated centrally. The organisation has developed quality assurance reporting processes. Regular meetings are held and the services users attending are able to give feedback to the management of the home and their views are heard by the representatives of the organisation that also attend. The record from a recent very detailed audit by the organisation was evidence of the organisations quality assurance monitoring. Records are stored securely and access is appropriately restricted. CSCI Care Home Regulation 26 visit reports by the provider are made on a monthly basis. The home has notified the Commission of reportable events between inspections via the Care Home Regulation 37 reporting process. Records of equipment servicing and routine appliance testing were examined. All were in order for the lifts, hoists and fire safety equipment and weekly fire alarm testing. Other servicing records seen included the telephone system, kitchen and laundry equipment, gas safety check, hot water safety valve checks and the nurse call system check. Waste contracts are in place for domestic, medical and clinical waste. Water tests for Legionella were satisfactory. The home has arranged and carried out four day first aid and health and safety training for all registered nurses since the last announced inspection. Accidents and incidents are reported and recorded in line with the data protection required format. St Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000003291.V353986.R01.S.doc 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 4 3 3 3 3 4 Version 5.2 Page 26 St Michael`s Cheshire Nursing & Residential Home 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 13(4)(c) Requirement Risk assessments for individuals identified as having high-risk behaviour affecting their safety and well being, must be clearly documented and strategies formalised to reduce the identified risks. Timescale for action 30/11/07 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. Refer to Standard YA6 Good Practice Recommendations To ensure effective and positive communication with the service user all expressions, behaviours and mannerisms should be recorded as a glossary in the care plan to inform staff. It would be helpful to remind people who live at the service and their families of the complaints procedure. The floor covering the physiotherapy staff toilet is damaged and should be repaired or replaced to ensure it can be thoroughly cleaned. DS0000003291.V353986.R01.S.doc Version 5.2 Page 27 2. 3. YA22 YA24 St Michael`s Cheshire Nursing & Residential Home Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Michael`s Cheshire Nursing & Residential Home DS0000003291.V353986.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!