Inspection on 23/07/08 for St Michael`s View

This inspection was carried out on 23rd July 2008.

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

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

Other inspections for this house

St Michael`s View 15/07/10

St Michael`s View 17/06/10

St Michael`s View 02/06/10

St Michael`s View 13/04/10

St Michael`s View 01/03/10

St Michael`s View 13/07/09

St Michael`s View 31/07/07

St Michael`s View 16/06/06

St Michael`s View 15/09/05

St Michael`s View 19/05/05

St Michael`s View 20/01/05

St Michael`s View 28/07/04

St Michael`s View 26/02/04

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Moor House

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Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE St Michael`s View St. Michaels Avenue North South Shields Tyne And Wear NE33 3BP Lead Inspector Irene Bowater Key Unannounced Inspection 23rd July 2008 09:15a 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 View DS0000000270.V368618.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 View DS0000000270.V368618.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Michael`s View Address St. Michaels Avenue North South Shields Tyne And Wear NE33 3BP 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) 0191 455 1215 0191 455 1238 stmichaels@schealthcare.co.uk Ashbourne Homes Ltd Sonia Pharoah Care Home 64 Category(ies) of Dementia (32), Old age, not falling within any registration, with number other category (33), Physical disability (2) of places St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places: 33 Dementia - Code DE, maximum number of places: 32 2. Physical disability - Code PD, maximum number of places; 2 The maximum number of service users who can be accommodated is: 64 31st July 2007 Date of last inspection Brief Description of the Service: St Michaels View Care home is owned by the Southern Cross, which was first registered in November 1994 and now accommodates 32 older people of mix gender for general nursing care and another 32 persons with mental ill health, 16 of who may also have a physical disability. The home does not provide intermediate care services. It is situated in a residential area and convenient for the town centre of South Shields. It is close to local train and bus transport. The seaside, shopping outlets, local theatres and social amenities are close by. The local shops and a post office are within easy walking distance of the care home. St Michaels View is a modern single storey care home, custom designed and built to provide facilities and services in 2 distinct separate units. There are in total 4 lounges, 2 dining areas and bedrooms with en-suite facilities. There are 2 internal courtyards both with wheel-chair access. The home is decorated and furnished to a good standard, and in keeping with the age, character and style of the building. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 5 Fee rates vary in the home: Private nursing £547, Medium Band £456, Continuing Care £494. The free nursing care element is set nationally. Private nursing dementia care£547,Medium Band £466,Continuning Care £504. Dementia care residential £365 .The free nursing care element is set nationally. Personal items such as clothing, toiletries, newspapers and outings are not included in the fee rates. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. Before the visit: We looked at: • Information we have received since the last visit on 31 July 2007. • How the service dealt with any complaints and concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service and their relatives, staff and other professionals. The Visit: An unannounced visit was made on 23 July 2008. This visit started at 09:15 and was completed at 16:00. During the visit we: • Talked with people who use the service, relatives, staff, the manager and visitors. • Looked at information about the people who use the service and how well their needs are met. • Looked at other records, which must be kept. • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. • Looked around the building to make sure it was clean, safe and comfortable. • Checked what improvements had been made since the last visit. • We told the manager what we found. What the service does well: The staff collect information together about the person before anyone moves into the home to make sure they can meet their needs. Visitors are always welcomed and there are links with the local community. Staff are respectful and sensitive with people when helping them or when speaking to them. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 7 The activities available to people are tailored to individuals requirements and staff work hard to provide a wide ranging social and activities programme. The menus offer a variety of well-cooked nutritious meals. People can enjoy a healthy, well-balanced and interesting diet. Clear information is available should anyone have a concern or complaint about the care or service they are receiving. The registered manager makes sure that all checks and clearances are received before staff are employed. The home supports people with dementia and other illnesses well. The dementia care unit is particularly well organised and furnished with stimulating objects and activities that attract people and engage their interests. Staff are trained well so that they understand the needs and behaviours of people, which in turn promotes their well being. The home has a good standard of decoration and furnishings. All bedrooms are a good size and all have their own private en-suite toilet. Lounges are comfortable, warm, bright and cheerful. Bathrooms are also well decorated and warm. There are good arrangements for supporting people to keep their personal monies in a safe place if they want. Comments from surveys include: “The care staff at all levels are of a high standard” “They try their best to help each person live a happy life” “They keep me informed about B and they telephone if there are any changes” “If I had a complaint I would go to the manager and talk to them about my worries and complaints” “The staff are very helpful in this home” “Good recreational activities I must give the staff credit as they all join in with activities and fun is had by all” “They give kindness and patient care, always cheerful and helpful” “There is always a warm greeting and all staff are friendly and courteous” “They are committed to delivering a high standard of cleaning in the home” St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? What they could do better: Care plans need to be updated following the advice of Speech and Language Therapists. Regularly review the staffing levels especially at peak times. Make sure new wardrobes are properly fitted; doors are aligned when new carpets are laid and repair radiators. Make sure that risk assessments are available when using wheelchairs with out proper footrests. Better access to transport would make it easier to provide more activities outside the home. Comments from surveys included: “I am not aware if the staff are qualified to look after people with Dementia” “I feel they are overstretched because they sometimes work short” “People do not always get an afternoon drink if they are short staffed” “Make sure there are enough staff on duty at night” “Employ more staff”. All of the comments were shared with the manager for her to look into and put right. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 9 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 View DS0000000270.V368618.R01.S.doc Version 5.2 Page 10 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 View DS0000000270.V368618.R01.S.doc Version 5.2 Page 11 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): 3, Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive clear information about the service and a comprehensive assessment of need before admission. This helps them make the right decision about using the service. EVIDENCE: The home sets out the aims and objectives of the service in a Statement of Purpose, which is readily available. There is also a Service Users Guide that sets out the values of the home. This makes references to supporting the diversity of needs, cultures, and beliefs of all those involved in the home. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 12 Before anyone is admitted to the home a full needs assessment is undertaken by a Care Manager, Home Manager and where necessary the nurse assessor. From this information the staff complete a care plan based on individual needs. Before coming to live in the home people can come and visit and spend some time getting to know the home. Also the home confirms in writing to each individual that they can meet their needs and everyone has a contract that sets out the terms and conditions while living in the home. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Access to health care is good and detailed care planning demonstrates that peoples’ needs are being fully met. EVIDENCE: Each person has a plan of care based on the admission assessment carried out by care managers, the home manager and where necessary nurse assessors. Staff complete pressure sore risk, dependency, moving and handling, nutritional assessments using the Malnutrition Universal Screening Tool (MUST), continence and fall risk assessments. These tools help the staff understand the level of risk each person and helps them complete a care plan. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 14 Where people have been assessed as needing help with mobility the care plans specify the moving and handling techniques or the specialist equipment needed. Care plans and risk assessments are reviewed and generally updated on a monthly basis. Staff have contacted the Speech and Language Therapists (SALT) when there have been concerns about people having difficulty swallowing and being at risk of choking. Detailed information from the SALT team is available in the care plans but staff have not updated the plans to show what diet and fluids those people need. People who have been identified at having lost weight have risk assessments in place to show how they are being supported with eating and drinking. Weekly weights are recorded and the records show that weights are stable or increasing. Should anyone loose weight the staff said they would contact the GP and dieticians for advice. Care plans show what management arrangements are in place to show what staff need to do when someone presents with any behaviour that would challenge. Appropriate pressure relieving devices are available. Several people have air cell mattresses and cushions to prevent pressure damage. Advice is sought from, occupational therapists, tissue viability nurses, speech therapists and continence advisors. Visits from the multi disciplinary team are recorded in individual care plans. Information about people’s previous lifestyles and preferences are being recorded. And plans show that a person centred approach to care is being given. For example, staff record if anyone has preferences about having help with personal care by male or female carers, one person likes football, darts and snooker, another gives details about enjoying gardening and walks along the sea front. Other plans show how staff support individual religious preferences. Everyone has access to all NHS facilities to ensure their healthcare needs can be met. There are regular visits from GP’s and other health professionals including, dentists, opticians and chiropody services. Medication policies and procedures are available for staff to use. The nursing staff are responsible for the safe administration of medicines to all of the people living in the home. Records are in place for all medicines received, administered and disposed of. An audit of Controlled Drugs and the Medicine Administration Records (M.A.R.) showed no discrepancies. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 15 Many of the staff have worked in the home for some time and know the people they care for well. All of the staff worked very hard to make sure everyone was treated with respect and their rights to privacy and dignity maintained. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities to take part in meaningful activities and keep control of everyday decisions are good, and mealtimes are organised. This makes sure people can lead full and active lives. EVIDENCE: The home benefits from an enthusiastic activities person who organises events on an individual and group basis. There is lots of evidence in both units of events that have taken place both in and out of the home. Although there is a designated person to plan leisure and social events the staff encourage and support people to take part in activities that they choose. The staff also get involved by providing various “shows” to entertain people. Comments from surveys included: “The entertainment officer does her best to provide entertainment but there is little that caters for my needs.” St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 17 “The activities coordinator does a lot for the residents although many can’t join in” “I think they put on good recreational activities” “The activities manager is just great and I must give staff credit as they all join in with activities and fun is had by all” The home has two separate units, which provide general nursing and nursing care for those with a dementia type illness. Both units have lots of information about past and present events. People have their stories, artwork and poetry displayed on the corridor walls. Murals decorate the walls and some corridors have been named after local streets. Stimulating objects and pictures decorate the Cleadon Unit. Pictures of old film stars and entertainers decorate the walls and murals made out of materials that can stimulate the mind when touched are available for people to stop at and admire and feel. One room is decorated as a “pub”. Some people and their relatives enjoy having lunches and chatting in this room. Other themes include “Billy the Butcher” with paintings of various meats in the “shop window”. There is also a grocers and sweet shop window. These show foodstuff from the war years onwards and provide stimulation and discussion about people’s previous lifestyles. There are weekly afternoon teas and the manager holds surgeries so that people can chat and discuss any concern that they have. People also have the opportunity of attending services and meetings held by different religious and faith groups. There is quiet sensory room where people can go to relax on an individual basis. People on both units can access the secure and sheltered garden areas, which are set in a courtyard theme. Visitors are welcome at any time and are able to use the lounges or their relatives’ bedrooms for visits. It was confirmed that there are no restrictions regarding visiting times. Information about advocacy is available in the home. Many people have brought small items with them making their rooms homely and reflective of their previous lifestyles, religious beliefs or cultural backgrounds. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 18 There are dining rooms on each unit. Should anyone want to eat their meals in their own rooms this service is readily provided. Tables on both dining rooms were set for meals. This includes tablecloths, napkins, crockery, cutlery and condiments. Choices for lunch were pork or broccoli and cheese bake with, sprouts, mixed vegetables and roast potatoes. Apple pie and custard was served for dessert but there were alternatives such as yoghurts and ice cream available. The meal was of ample portion size and nicely presented. On the Cleadon unit staff only offered tea to drink, no one was offered sugar and no one had a saucer. Two people sitting at the back of the room did not have their table set and one person did not eat any of the meal whilst the other person ate food off both plates. At least nine people need assistance at mealtimes and it was difficult for staff to give everyone individual attention. Staff confirmed that they record what people have eaten or otherwise and they make sure alternatives are given and recorded. People spoken to said: “ The meals are generally good” “I can’t complain” “There is always plenty to eat” St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good complaints and protection procedures are in place. People can be sure that their views are always listened to and that they are protected from harm EVIDENCE: The Company have a detailed complaints procedure, which is easy to understand, and it is readily available in the home. The home keeps a full record of all complaints including detail of any investigation and actions taken. There have been no complaints recorded or referred to the Commission since before the last Inspection. Clear safeguarding adults policies are available and staff were able to say what they would do should they be concerned about care practices. The manager has attended alerter, responsible person, safeguarding managers and investigation training. This makes sure that any concerns about protecting people are dealt with appropriately and in line with Local Authority guidance. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 20 Care staff have completed safeguarding training which links into the Local Authority procedural framework. There are currently no safeguarding referrals reported to CSCI or Local Authority. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and a pleasant, clean and comfortable place for people to live. EVIDENCE: The home is a single storey building, which has two separate units. One is called the Cleadon and the other is the Marsden. Both units have lounges, dining rooms, bathrooms, toilets and all of the bedrooms have an en-suite facility. People on both units can access pleasant safe courtyard and garden areas. Corridors are wide and seating areas have been provided in some areas. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 22 The communal areas on both units were nicely decorated and furnished. And the manager and staff have put an enormous amount of effort on making the Cleadon unit more stimulating and appropriate to the needs of the people who live there. People who live on the Cleadon unit are occupied in meaningful activity in an environment that is interesting, accessible and suited to their needs. Pictures and small pieces of memorabilia decorate the surroundings. This helps to provide reminiscent experiences, while at the same time providing an environment where people feel safe and secure. People who live on the Marsden Unit can also be occupied in meaningful activity and the corridors are decorated with their artwork, photographs of events and poetry. There are also pictures of the area as it was for example loading the coal from Tyne Dock, pictures depicting the trolley bus transport of the day and making the river Tyne wider. All bedrooms have an en-suite facility and there are bathrooms and toilets close to all areas. Bathrooms and shower rooms have plenty of aids and adaptations so the people can use these facilities easily and safely. All bathrooms, shower rooms and toilets have been redecorated in the past twelve months. Some refurbishment of bedrooms is taking place and new carpets have been provided. Not all of the new wardrobes have been fitted to the walls and some doors have to be refitted as they are catching on the carpets. Some of the radiator tops are loose and ill fitting. Since the last visit a loop system has been installed for those who may have difficulty hearing. The laundry area is well–equipped, organised and clean. Staff were able to discuss infection control procedures and were observed to follow them at all times. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and systems around recruitment, selection and training of staff are good and meet the range of needs of the people using the service and protect them from harm. EVIDENCE: At the time of the site visit there were fifty-seven people living in the home. Each unit is staffed separately. During the day the Cleadon unit gas two qualified nurses and four care staff and the Marsden unit has one qualified nurse and four carers. Overnight each unit has one qualified nurse and 2 care staff. Each unit is sprawling and although staffing levels are maintained many people have high dependency needs. This means that sometimes it is difficult to immediately find a member of staff, as they are busy in someone’s room. During the visit there were times when there was no one about as staff were busy helping individuals in the privacy of their bedrooms, bathrooms and toilets. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 24 The staffing levels on both units need to be reviewed on a regular basis to make sure everyone’s needs can be met. Comments from the surveys all raised the same issue comments included: “They need more staff” “Staff are hard working but sometimes there is not enough of them” “I am not aware if the staff are qualified to look after people with dementia” The manager is supernumerary. There are sufficient ancillary staff including domestic, administration, maintenance, and activities person, cook and kitchen assistants. The records for recruitment were satisfactory. There was evidence of Criminal Record Bureau checks, Protection of Vulnerable Adult checks, two written references, proof of identity and professional identity numbers for registered nurses. Mandatory training for moving and handling, fire prevention, first aid, and infection control and food hygiene is up to date. There is training programme in place. Other training includes Infection Control, Palliative care, Yesterday Today and Tomorrow, catheter care, safeguarding adults and tissue viability. A survey from a professional said: “They can improve by providing more training and support for staff by the Company” St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 25 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): 31 ,33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run by a competent manager who makes sure that good quality assurance and safety systems are in place. This makes sure that people receive a good quality of care. EVIDENCE: The manager is first level Registered Mental Health Nurse .She has been registered with the Commission and had completed the Registered Managers Award. And she is experienced and has made changes, which has improved the quality of the service. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 26 Audits of all care and other services are carried out with action and outcomes recorded. The regional manager visits on a monthly basis and completes a separate report. These reports are to make sure the quality of the home continually improves. The AQQA was completed and the information gave a reasonable picture of what was happening in the home and information about how it plans to develop over the next year Staff and relatives meeting take place with minutes kept. The manager holds regular “surgeries” so that everyone has the chance to discuss anything that concerns them. The personal allowance records demonstrate that receipts and double signatures are maintained for all transactions. These could be cross-referenced and weekly checks are carried out to make sure there are no discrepancies. All mandatory training was up to date. Health and safety risk assessments are clear and kept up to date. Accidents are recorded and best practice guidance is used to track trends, which prevents as far as possible the same accidents occurring. Staff did not always use the footrests when people were being transferred using wheelchairs. This means that there is a possible risk of injury to people’s feet and legs. If foot rests are not to be used for individuals a separate risk assessment needs to be completed Internal maintenance checks are up to date and external service certificates are available and up to date. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 27 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 3 X 3 X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 28 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(1) Requirement The registered persons must ensure that care plans are updated and follow the recommendations of the Speech and Language Therapists. The registered persons must review the organisation of mealtimes. The registered persons must ensure that the new wardrobes are fixed to the walls. The bedroom doors need aligning when new carpets are fitted and loose radiator tops need repairing. The registered persons must ensure that the practice of transferring people in wheelchairs with using footrests is stopped unless individual risk assessments are in place. Timescale for action 01/09/08 2 3 OP15 OP24 12 16,23 01/09/08 01/09/08 4 OP38 12,13,23 01/09/08 St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 29 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 OP14 Good Practice Recommendations The home should have reasonable access to suitable transport to enable service users to use community facilities. St Michael`s View DS0000000270.V368618.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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