Inspection on 11/09/06 for Stella Maris

This inspection was carried out on 11th September 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

Stella Maris 06/03/06

Stella Maris 29/09/05

Stella Maris 02/03/05

Stella Maris 01/09/04

Stella Maris 02/03/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Stella Maris 8 Ellenborough Park South Weston Super Mare North Somerset BS23 1XW Lead Inspector Nicola Hill Key Unannounced Inspection 11th September 2006 09:30 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 Stella Maris DS0000008058.V312107.R02.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. Stella Maris DS0000008058.V312107.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stella Maris Address 8 Ellenborough Park South Weston Super Mare North Somerset BS23 1XW 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) 01934 632817 NONE Mr Ralph Timothy Morris Mrs Susan Anne Bartlett Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Stella Maris DS0000008058.V312107.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate 18 persons aged 65 years and over requiring personal care. 6th March 2006 Date of last inspection Brief Description of the Service: Stella Maris provides care and support for older people. Situated close to the beach and parks in the southern part of Weston-super-Mare, the home is well positioned for the local amenities and services. The accommodation comprises two floors, the upper floor being served by a stairlift and a ground floor extension to the rear. The majority of rooms on the ground floor (12) seven of which have en-suite facilities; there are six rooms on the first floor and landing of which three have en-suite facilities. The home also benefits from two lounges, one a designated quiet lounge with library facilities. There is a large dining area. The home is sited within walking distance of the seafront and overlooks a private park. Stella Maris is situated near community facilities such as churches and shops. Stella Maris DS0000008058.V312107.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection of Stella Maris took place on the 11th September between Nicola Hill, Inspector, and Sue Bartlett the manager for the home. On the arrival several of the residents were sat in the front lounge, and they greeted the inspector. The inspector spoke with the manager and reviewed records and documentation relating to the day-to-day running of the home. The residents had a morning activity, which was led by the staff at the home; this was a sing along to their favourite tunes. In the afternoon several residents were accompanied by staff on a visit to Blagdon Water gardens. The inspector managed to speak with seven of the residents during the day, several of whom declined the outing to Blagdon because of infirmity or preference to stay in their own home. All the residents who spoke with the inspector were full of praise for the home, and enjoy living there. Stella Maris is a comfortable and friendly home, with an experienced staff team, and has excellent standards in some areas of its service provision. The fee level at the home starts at £320 per week. What the service does well: The home has friendly atmosphere, with residents familiar with staff that they know well. One resident had been in the home 13 years and she stated that she is very satisfied with the service that she received and she wouldnt change anything. The manager, staff team and the owner the home are responsive to recommendations made through the inspection process. They are extremely pro active in seeking the views of their residents as to how the service is being run and whether it meets expectations. There is always an ongoing programme of improvement, and particularly environmental improvements in order to provide a well be decorated and maintained home for the residents. The overall priority for the home is the comfort of the resident and their quality of life of the home. The benefit of Stella Maris being a smaller home was discussed with residents, as everyone knew each other. One of the residents acknowledged that although there were activities to attend and the staff tried very hard to encourage them to join in, it was their choice. It was also apparent that wherever possible staff supported residents to attend outside activities such as their local church, or WI meetings. None of the resident expressed any dissatisfaction with the service they received at the home; they were very Stella Maris DS0000008058.V312107.R02.S.doc Version 5.2 Page 6 complimentary about the staff and their approach to them. The food at the home was also praised as residents felt they had a good variety of meals to choose from, and if they are hungry or required a drink, the staff made it for them. What has improved since the last inspection? 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. Stella Maris DS0000008058.V312107.R02.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 Stella Maris DS0000008058.V312107.R02.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 Quality in this outcome group was excellent. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. The home provides prospective residents with a statement of purpose and a brochure that together provide good clear information about the home. EVIDENCE: The manager and inspector discussed the statement of purpose for the home and its content. Prospective service users rarely requested a copy of this, however the manager stated that she ensured that all enquirers were sent a brochure and a copy of the statement of purpose. The manager and the owner are currently reviewing the document to include the improvements made in the service, the quality assurance carried out at the home in the form of resident meetings and quality audit the home, and the increased activities and planned weekly trips, all of which promote the service. Stella Maris DS0000008058.V312107.R02.S.doc Version 5.2 Page 9 All of the residents at the home have an individual contract; the manager ensures that wherever possible this is signed by the resident. The majority of placements made at the home are funded by social services. They issue their own contract with the resident and to the home. The inspector was able to read the pre admission assessments for the newest service users to the home. These are supported by a management assessment, which identifies the specific needs of the resident. The manager ensures that when she meets prospective residents, that they are invited to visit the home and view the facilities offered, and also to meet some of the residents already there. The home also offers respite to people living in the community, and sometimes people can use a respite stay at the home as a trial run before moving in on a permanent basis. The home does not offer intermediate care. Stella Maris DS0000008058.V312107.R02.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 Quality in this outcome group was good. The aims and objectives of the home reinforce the importance of treating residents with respect and dignity. Each resident has a plan of care, which is agreed with him or her; the plan also includes risk assessments where necessary. The medication policy and procedures are good but require reinforcement with staff. EVIDENCE: The service user plan of care is generated from a comprehensive assessment format used at the home. All of the assessments are individual, and the plan of support resulting from the assessment is tailored to meet the specific needs of the resident. No preprinted care plans are used at this home. This means that the care identified is very much a personalized plan, and wherever possible the manager tried to interest and encourage residents to state their Stella Maris DS0000008058.V312107.R02.S.doc Version 5.2 Page 11 preferences. The inspector spoke with some of the residents about the care plan. Some of them expressed the opinion that they were confident that staff at the skills to meet their needs, and that they could ask or tell them what they wanted. The idea of a formalised care plan for some older people can appear to be quite intrusive into their personal life. The plans generally are reviewed by the manager, and are changed according to presenting need. The home does have a resident who was referred by the mental health team and therefore has a Care Programme Approach. The inspector was able to see evidence of this being reviewed regularly and continued input from the team where necessary. Each of the residents, wherever possible, retained their own GP on admission to the home. This is in order to maintain a continuation of service from a GP who hopefully well know them. The residents generally are able to inform staff about prevailing health conditions. The care assessment carried out by the manager identifies any health-care needs that should be met. For example, some of the residents are more immobile than others, and may require a pressure relieving cushion. The residents also confirmed that the staff are very supportive in their encouragement for exercise and in particular attending meals in the dining room. This encourages residents to be mobile as well as to be involved in social interaction with other people. The staff at the home have recently attended a training session on falls awareness, and will be implementing knowledge gained to try to prevent unnecessary falls at the home. The manager discussed with the inspector the access to specialist support such as dental services. Where possible residents are supported by the family to attend appointments away from the home. If that is not possible then the manager and the key worker will support residents to be visited by the appropriate healthcare professional. The medication system used at the home is the Nomad trays supplied by the local pharmacist. All the staff who administer medication have attended training given by the local pharmacist and may have completed a distance learning course on medication. The medication system and records were checked and found to be accurate; this included the controlled drugs held on the premises. The only issue with medication is that some staff are not signing medication records appropriately, however the manager is aware of this and had been spot checking the record sheet to ensure compliance. On the day of inspection there were several entries, which weren’t signed, however the manager was aware of who had not completed to medication sheet was taking appropriate action. From the inspector’s observation and from the evidence given by residents at the home the residents at Stella Maris are treated with respect. Their right to privacy is supported by the way in which the staff knock before entering rooms Stella Maris DS0000008058.V312107.R02.S.doc Version 5.2 Page 12 and all the staff address people by their preferred name. Some of the service users have telephones in their rooms, while others take calls on the house phone. In order that there is privacy on the house phone, the phone is mobile. No rooms at Stella Maris are shared, and therefore all the residents have their own private space. It was noted that residents bring in a lot of their own furniture, pictures and are supported in decorating their rooms to their own personal tastes. Stella Maris DS0000008058.V312107.R02.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 group was excellent. Residents are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. The home has sought the views of residents and considered their varied interests and abilities when planning the routines of daily living and activities. Routines are very flexible and residents can make choices in major areas of their life. EVIDENCE: The inspector observed that the routines of the home are flexible and varied so that activities can be planned and take place. For example, on the day of inspection the residents went out on a trip to Blagdon water gardens. However, in the morning they had an opportunity for a singsong and social discourse with others, facilitated by the staff. Those who had not planned to go out in the afternoon particularly enjoyed this. Up-to-date information about activities is available on the resident notice board, and is regularly circulated so that residents are aware of what is going on. It was interesting to hear from the residents that although they didnt enjoy going out on the bus Stella Maris DS0000008058.V312107.R02.S.doc Version 5.2 Page 14 because of the mobility problems, they were able to pick the activities they preferred to attend and probably attended something every other day. This suited one resident in particular because the she enjoyed her own company, but also had several visitors across the week. She said she attended the activities that fitted in with her personal routine. Service users stated that visitors are always made welcome and made a cup of tea. One resident informed the inspector that when her son came to visit he didnt wait to be offered cup of tea and he went down and found whoever was in the kitchen to make him one. She stated he felt very comfortable doing so and staff had always been helpful. The staff ensure that they maintain good relationships with friends and carers so that they can facilitate their involvement with the residents care. The residents also enjoy attending local churches. It was confirmed that staff facilitated visits and that in many cases the home contacted the church and ensured that volunteers came to pick residents up and take them to services on a regular basis. The manager has supplied a copy of the menu plan to the inspector as part of the pre-inspection information. The inspector looked to residents for information about the meals provided at the home. They confirmed that there was a wide variety of meals and that if there was nothing on the menu that they liked, then they would be given another alternative. The inspector was able to see the meal produced for the lunchtime, and noted that it was well presented and that residents have very wide choice. The residents are able to choose a week in advance which meals they would like. If someone changes their mind there is capacity to accommodate it. The majority of the residents have their meals in the dining area, which had been nicely decorated and is a very airy room with an air of calm and quiet. Mealtimes are also an opportunity for the residents have social contact with each other and to discuss and enjoy their food. Stella Maris DS0000008058.V312107.R02.S.doc Version 5.2 Page 15 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, 18 Quality in this outcome group was excellent. Residents and others associated with the home state that they are extremely satisfied with the service provision. They feel very safe and well supported by the manager and staff team. The services principal aims and objectives include the promotion of the individuals right to live an ordinary independent life when ever possible. EVIDENCE: The manager maintains a complaints/comments book. The inspector could read that any comments made by residents were recorded and there was an outcome. The last entry was made on behalf of a resident who had requested a lock on the door of his room. Currently the door is lockable from the inside but not lockable from the outside. As an interim measure the manager supplied the resident with a special key, which enabled him to lock the door from outside, whilst a suitable lock is sourced. The resident confirmed that this arrangement was satisfactory to him and that he was pleased that he had asked for that to happen. The residents confirmed to the inspector that if they have problems they were happy to go to Sue about them. They also confirmed that the resident meeting was a place where they could raise concerns or complaint; one Stella Maris DS0000008058.V312107.R02.S.doc Version 5.2 Page 16 resident also acknowledged that when living in a small community they were bound to be things that didnt suit everybody and that some degree of compromise was always necessary. All the residents who spoke with the inspector were able to self advocate and tell the inspector about their personal lives. Some of them had more control and autonomy than others. Some residents were no longer able to control their own financial affairs. The manager was able to demonstrate when the independent advocate or agent was to act on the residents’ best interest. The staff have received training on the awareness of adult protection issues, however there have been no issues raised at the home. Stella Maris DS0000008058.V312107.R02.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, 21, 23, 26 Quality in this outcome group was excellent. The management staff encourage residents to see Stella Maris as their home. It is not purpose-built but provides a well maintained, safe and attractive home with equipment provided to meet individual residents’ needs. The rooms are well planned; several have ensuite facilities and are larger than the average size. The home is well lit, clean and tidy. EVIDENCE: All of the rooms at the home are single rooms. They are easily accessible either because of being on the ground floor or through use of the stair lift. Several of the rooms have ensuite toilet facilities, and there are sufficient toilets and bathrooms to meet the standard. The home is well maintained and is decorated to ensure that the premises are pleasant for the resident living Stella Maris DS0000008058.V312107.R02.S.doc Version 5.2 Page 18 there. The outside of the home is well-kept in contrast to the adjoining hotel. The garden of the home has wooden seats for residents to use and the borders are well maintained and well stocked. The border on the driveway to the home currently needs some attention, and it is planned that tree roots need to be removed as they are causing cracks in the driveway; however this work will be completed at a suitable time of year. There are plans to replace the windows in the rear of the building, and to replace the carpet in the hallway that has worn through the effects of sunlight. The residents bedrooms at the home generally all very homely and the residents know they can bring in furniture from home to decorated and make it to their personal space. The outdoor area at the back of the building has a raised flower bed, which has been recently planted up by a resident and maintained by others. The home has made adaptations to ensure that it is easily accessible. The corridors have handrails to facilitate residents with mobility problems. The home is well lit and uses light decoration to maximise the light in the corridors. The stair lift, although rather old, is regularly serviced and the residents are used to operating it. The conversion of the upstairs bathroom into a shower room has been very successful. One resident stated how much she enjoyed having a shower as opposed to having to get onto the bath chair and be hoisted into a bath. Currently the home does not have a hoist to lift people from the floor should they fall. This has been unnecessary in the past as the residents were reasonably mobile. All the staff have had training in manual handling techniques and would be able to assist a resident from the floor if the resident were uninjured. However, the residents had a small number of falls, and if needed the paramedics are called to ensure that no injury had occurred. The home is very pleasant and clean. There has been a new member of staff appointed to clean the home and residents of expressed their satisfaction with the standard of cleanliness at the last residents meeting. The inspector noted that the hand washing facilities for staff are fairly limited and would recommend to the manager that, with the on set of winter and prevailing infections such as Norwalk viruses, infection control precautions are reviewed. Antibacterial hand wash should be introduced to basins in toilets and bathrooms or alcohol based hand rub given to staff to use. The residents laundry is washed on their behalf by the staff; there were no complaints about this from the residents. The laundry equipment in the home is industrial, and the manager stated that the equipment had far less breakdowns than with the domestic type that she had in the past. Stella Maris DS0000008058.V312107.R02.S.doc Version 5.2 Page 19 The kitchen area of the home would benefit from being repainted as the paint is flaking in some areas. It is also noted that since the last inspection new equipment i.e. new refrigerator freezer and microwave have been purchased for the kitchen. Stella Maris DS0000008058.V312107.R02.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 group was good. Residents have confidence in the staff that care for them. Residents report that staff working with them are very skilled in their role, and are consistently able to meet their needs. The service has a good recruitment procedure that clearly defines the process to be followed. EVIDENCE: The staff team at Stella Maris is very settled and the staff members enjoy good relationships with the residents. The inspector could observe the interactions between staff and residents. It was clear that the overriding principle for the staff is that the residents are as comfortable as possible. It was noted from the minutes of the residents meeting that some residents felt that staff did not have enough time for them in the mornings. The manager has discussed this with the team and reworked the routine for the mornings in order to respond to the residents’ observations. The staff team have made progress with training; it has been difficult to access NVQ 2 for all care staff. The current situation is that two staff members commence the course in October, whilst the two others will start in the New Year. This means that the home does not meet the ratio of 50 as quoted in the standard however evidence suggests from both documentation, the history of the home and the residents that those Stella Maris DS0000008058.V312107.R02.S.doc Version 5.2 Page 21 staff working at home despite not being NVQ 2 qualified, are providing a good standard of service. The manager was able to demonstrate that staff have attended various short training courses which enhance the service provided at the home. For example, they have recently attended a prevention of falls course run through the Primary Care Trust. The inspector was able to review the recruitment records for staff working at Stella Maris. The recruitment process had been followed and there was evidence of induction of staff to the home and its working practices. The staff level at the home fluctuates in response to the number of residents and the activity needed. For example, in the morning of the visit there were care staff, ancillary staff and the manager on duty, whilst in the afternoon when several residents had gone out the staff level was reduced. The opinion of the residents about the level of care and support received from the staff team was that the staff work hard to meet their individual needs, and that nothing is too much trouble. Several residents stated they felt they were lucky to be living at Stella Maris because of the caring support from the staff. Stella Maris DS0000008058.V312107.R02.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, 33, 35, 38 Quality in this outcome group was excellent. The manager is experienced and highly competent to run the home and meet its stated aims and objectives. There is strong evidence that the ethos of the home is open and transparent with the views of both staff and residents listen to and valued. EVIDENCE: The registered manager has worked at the home for a number of years, and has attended training to ensure that she is updated in her skills and knowledge so that the home is managed effectively and in compasses current work practices. There are clear lines of accountability within the home, and the owner Mr T. Morris visits the home on a regular basis to provide support to the manager. Stella Maris DS0000008058.V312107.R02.S.doc Version 5.2 Page 23 The manager was deemed to be approachable by the residents who see her on a daily basis and recognise her as someone who will listen to them and take appropriate action should they have a problem. The manager has good relationships with the staff team and supports staff with training opportunities. The residents meetings are a good way to allow residents to have a voice in the day-to-day running of the home. All residents receive an individual invitation to the meetings, and if they choose not to attend they can submit written comments. The minutes from the meeting are published and provided individually to residents and include comments from the owner. The residents generally are happy to attend, especially as they could recount to the inspector issues they had raised that had been acted on. The staff team also have meetings to raise issues and share information. As such there is no annual development plan for the home however when the owner visits the home he discusses with the manager developmental issues. From this the inspector was told about the environmental developments due to take place at the home. The owner undertakes regulation 26 visits and provides a report to the Commission. The manager has developed an internal self-audit process to provide for continuous self-monitoring of the effectiveness of the policies and procedures implemented at the home. The manager acts as an agent for some residents, and there are suitable records kept of all transactions entered into on behalf of the residents. Insurance cover is provided for the business. The manager of the home works closely with the staff team ensuring that practice in the home is good and that any training needs are identified. She is working with staff to achieve regular supervision, and although the standard of six sessions per year has not yet been achieved, there is evidence that staff are regularly supervised. The new domestic appointed to the home also has her training needs taken into consideration and will be working towards an NVQ in hygiene. The implementation of health and safety at the home is good; there are a minimal number of accidents at the home and very few falls. The staff at the home all undertake basic first aid. The manager carries out risk assessments of the environment to ensure that the home is secure and safe for staff and residents. Fire safety procedures are implemented as per the recommendations from the Avon Fire Brigade. Stella Maris DS0000008058.V312107.R02.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 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 3 18 3 3 3 3 X 3 X 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 Stella Maris DS0000008058.V312107.R02.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. Standard Regulation Requirement Timescale for action 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 OP26 Good Practice Recommendations The manager should undertake a review of infection control measures. Stella Maris DS0000008058.V312107.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. Extracts may not be used or reproduced without the express permission of CSCI Stella Maris DS0000008058.V312107.R02.S.doc Version 5.2 Page 27 - 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. 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