Care Home: Muriel Street Resource Centre

What the care home does well Comments received were: "On the whole I think the home does a very good job" "We are a very happy home" "I am very happy with the care they give xxxxxxx; so far they do a good job and they work very hard." People moving into 37 Muriel Street can be reassured that their care needs are assessed so that their needs will be met in the way that they wish. They will also be treated with respect. People living in the care home are encouraged to follow their preferred lifestyle and continue important relationships with family and friends. They are also encouraged to engage in social occasions to experience new activities. Where they wish to spend time alone, this is respected. The activity programme has been developed to be varied. It includes opportunities for both group and individual activities. The home provides a variety of communal areas as well as ensuite bedrooms. Overall it is decorated, furnished, and maintained, to a good standard. The standard of cleanliness is also good. Current residents say they are very happy living in the home. They like the programme of activities. Many appreciate living in an area they know, close to family and friends. They describe staff as ` good`, `respectful, and `kind`. Staff enjoy working at the home. They say that the manager "nice" and "approachable" ` is very good",Members of the company running the home have very regular contact. They demonstrate a very active interest in the quality of the service to the residents. What has improved since the last inspection? The new manager returned the annual quality assurance assessment within the prescribed time scale. It gave clear information and demonstrated the improvements the home has made and what developments are stilled planned. CARE HOMES FOR OLDER PEOPLE Muriel Street Resource Centre 37 Muriel Street Islington London N1 0TH Lead Inspector Pippa Canter Unannounced Inspection 21st July 2008 10:30 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 Muriel Street Resource Centre DS0000054457.V367811.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. Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Muriel Street Resource Centre Address 37 Muriel Street Islington London N1 0TH 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) 0207 833 2249 0207 833 2253 manager.muriel@careuk.com Care UK Community Partnerships Ltd Ms Gladys Danquah Care Home 60 Category(ies) of Dementia - over 65 years of age (40), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (20) Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th August 2007 Brief Description of the Service: Muriel Street is a purpose built 60 bedded care home registered with the Commission for the provision of care for older people with dementia and mental health problems The home is owned and managed by Care UK Ltd, as part of a block contract with Islington Council. It is situated in a residential area within walking distance of Caledonian Road, where there are various shops and public transport. The accommodation is spread over three floors. One floor is residential only, with the others including nursing care. All bedrooms are single with en-suite toilets, showers and washbasins. There are assisted baths on the two nursing floors, and lifts and stairs to all three floors. All parts of the building are accessible to people who use wheelchairs. For safety reasons each floor has a keypad security lock on the exit door. As the service is block contracted the charge to people moving into the home is determined by a financial assessment carried out by Islington adult social services. The level of fees will be included in the final report. Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people using this service experience good quality outcomes. This unannounced key inspection was completed over one day and lasted a total of 6.5 hours from mid-morning until late afternoon. Prior to the inspection, the Commission for Social Care (CSCI) was made aware of concerns raised in a letter sent to Care UK and a copy sent to the Adult Protection Co-ordinator, Islington. The allegations made related to the personal care, staffing levels and attitude of staff. Whilst this was not the purpose of this key inspection to investigate the concerns raised as such, the concerns raised have been considered when assessing the relevant National Minimum Standards. The concerns are being looked into through an internal investigation. Islington Primary Care Trust and Social Service Department are aware of the investigation. Prior to the inspection, we reviewed the information that the Commission for Social Care Inspection had about the home. This included the Annual Quality Assurance Assessment (AQAA), which was completed and returned by the registered manager. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. We reviewed and summarised the incident reports supplied by the home. Postal questionnaires were circulated for people living in the home, well as health and social care professionals and staff. Surveys were received from people living in the care home, staff, a GP and relatives also made a contribution. We have looked at the information collected from the previous inspection and relevant information from other organisation. During the visit we looked at the premises and visited people in their own rooms with their permission. People living in the service and staff were spoken to and the serving of lunch was observed on two floors and there were other periods of observation throughout the day. Staff was observed going about their duties and interacting with residents. We followed the care for four (4) people who are currently living in the care home and a further three (3) other care plans were looked at. The care plans were compared with the care being given. The choice of care plans reflected people’s gender, specific health care conditions and cultural needs. The inspection focused on aspects of care, daily activities, staffing levels, supervision, complaints and adult protection. Staff recruitment and training records were looked at as well. Samples of health and safety records were seen. Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 6 All those who have contributed to the inspection process are thanked for their input. What the service does well: Comments received were: “On the whole I think the home does a very good job” “We are a very happy home” “I am very happy with the care they give xxxxxxx; so far they do a good job and they work very hard.” People moving into 37 Muriel Street can be reassured that their care needs are assessed so that their needs will be met in the way that they wish. They will also be treated with respect. People living in the care home are encouraged to follow their preferred lifestyle and continue important relationships with family and friends. They are also encouraged to engage in social occasions to experience new activities. Where they wish to spend time alone, this is respected. The activity programme has been developed to be varied. It includes opportunities for both group and individual activities. The home provides a variety of communal areas as well as ensuite bedrooms. Overall it is decorated, furnished, and maintained, to a good standard. The standard of cleanliness is also good. Current residents say they are very happy living in the home. They like the programme of activities. Many appreciate living in an area they know, close to family and friends. They describe staff as ‘ good’, ‘respectful, and ‘kind’. Staff enjoy working at the home. They say that the manager “nice” and “approachable” ‘ is very good”, Members of the company running the home have very regular contact. They demonstrate a very active interest in the quality of the service to the residents. What has improved since the last inspection? What they could do better: Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 7 The home has already made progress with the care plans. The level of detail in the care plans seen matches the level of need of each of the residents. However there is still room to make the care plans more individual by ensuring that preferred rising and retiring times, preferred times for bathing or showering and individual likes in activities. The manager in the home and the staff have supported residents and their relatives to record end of life decisions. Further work is needed to ensure that they reflect the cultural and religious needs of the people. 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. Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 8 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 Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 9 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 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People moving into the service can be confident that their needs are assessed and the service can offer them the care they require. EVIDENCE: The case files of four people were looked at, one of whom had been admitted since the last inspection. Service users referred to the care home are subject to the care management approach and are assessed by a care manager. This information is used to develop a community care plan, which is sent to the home. Prior to admission an experienced member of the staff at the care home will also a pre-admission assessment. This information is used to make a decision about the home can meet the new person’s needs and to develop an initial care plan. Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 10 Four people were case tracked as part of the inspection through the computerised record system. All had assessments in place. All other assessments had been completed such as manual handling, tissue viability, nutritional and continence. Risk assessments were also apparent. The outcomes of these assessments had been translated into the individual care plans. Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 11 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. The level of detail in the care plans seen matches the level of need of each of the residents, however the plans can be more individualised. Arrangements are in place to ensure that peoples’ health care needs are being met. Attention has been paid to safeguarding people who have their medication administered by care staff. EVIDENCE: A total of four care plans were looked at in detail. The daily records of a further seven people were included as part of the inspection. Five people were asked for their views. Managers and care staff were observed interacting with residents, whilst carrying out their duties. Comments received as part of the ongoing inspection process. • “The home does well by keeping Mum comfortable and she is always clean as is her room.” Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 12 • • • • • “All her medical needs are checked and kept up-to-date providing her with an air bed as she is bed bound; turning her frequently to prevent bed sores.” “Basic care is done well. I feel Mum is safe and in the best place for her given her needs.” “Generally I am happy with the care given.” “The home does well by keeping the residents happy and comfortable.” “Home does invite specialist advice from GP/mental health care team/ district nursing service” Last year the provider introduced a new electronic system for record keeping. Staff have been trained to use the system. Each person living in the care home has a care plan. These are being reviewed on a monthly basis. Risk assessments are also in place where needed, for such things as mobility, tissue viability (pressure sores), and fluid in-take. Residents are referred to the General Practitioner as necessary and to specialists such as Speech and Language Therapist. The level of detail in the care plans seen matches the level of need of each of the residents. However the care plans are not as individualised as they could be. A “Getting to Know You” questionnaire is part of the admission process but not all this valuable information is reflected in the care plan. The care plans need to reflect the personal preferences of the individuals such as preferred rising and retiring times, personal preferences for bath or shower and at what time of day as well as preferred activities. An inspection of the daily records for 8 residents revealed that 3 of them had been washed and dressed by the night staff. One entry recorded, “ XXX was already washed and dressed by night staff, lying in bed.” Reassurances were given that night staff would only assist residents with their personal hygiene if they were fully awake and restless to get up. People’s preferred rising time needs to be recorded and any deviation from this must be fully explained. Please see requirement 1. Feedback from staff is the retention of independence is a key principle of the home, along with dignity, respect, and privacy. People using the service and visitors confirmed this to be the case. Comments from staff showed that they respect peoples’ right to privacy. Observation of staff and resident interaction during the visit showed a high level of mutual respect. There is a clear warmth and affection for residents, and concern for their well being. Prior to the inspection the manager reported a serious drug administration error. As a result we have requested a pharmacy inspection. The manager has managed the situation appropriately and action has been taken to prevent a reoccurrence. In light of the request for a pharmacy inspection, a small audit of the arrangements for the administration of medication was taken. This included looking at a sample of medication administration charts was carried Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 13 out. The medication policies, procedures, and practices are now of a safe standard. The Annual Quality Assurance Assessment completed prior to the inspection recorded that the service had been in consultation with relatives from their relatives’ forum and agreement had been reached to set up end of life care plan and support group. The Homes’ GP was invited to the forum who explained the purpose of end of life plan. Leaflets have also been made available. An inspection of the care plans shows that end of life wishes are recorded. However the end of life plans do not always reflect the persons’ cultural and religious needs. Without this information recorded both the resident and the staff are vulnerable. The home needs to ensure that all relevant details are recorded. Please see requirement 2 Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 14 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. The lifestyle in the home matches residents’ expectations and preferences. Family, friends and the local community are encouraged to be involved. Meals are balanced and nutritious. EVIDENCE: Comments received as a part of the ongoing inspection process were:• I think the people are very well looked after but my greatest concern is that people rarely get out into the fresh air. No outings, just occasionally use the garden but all too infrequently in my opinion.” “I feel people are quite trapped on their one floor with lack of fresh air or outings. I realise there are constraints with the number of staff and finances but I do feel strongly that some more freedom of movement and access to fresh air should be addressed.” DS0000054457.V367811.R01.S.doc Version 5.2 Page 15 • Muriel Street Resource Centre • • • • “Mum is capable of conversation sometimes staff are too busy to provide much needed social interaction.” “I am not at the home all the time, but I feel more effort could go into social activities/trips.” “In my mother’s care they do try to encourage her to do things e.g. talking.” “Need more staff for the residents who can’t feed themselves. The staff do their best but if more than 2 residents need feeding staff can’t always stay with them till the meal is finished.” Since the above comments were made (September 2007) the home has developed a wider range of social activities. An activities organiser is in post and the programme of activities is clearly displayed. Feedback from people using the service say they enjoy and appreciate what is available and are clear that they have the choice to attend or not. Staff are keeping a record of each individuals’ participation in activities. However an examination of a care plan showed that more information had been recorded in the monthly evaluation about the activities the person had done than in the actual care plan. Again the information from the “Getting To Know You” questionnaire is not being translated into the care plan. Another example is that a key worker will record that a person likes to watch television but there is no record if there were any particular favourites. This is an area that had been earmarked for continuous development taking on board the needs of people with dementia for social inclusion. A comment received was, “Very good stimulation of clients via activity co-ordinator”. Visitors said that they are made to feel welcome and kept up-to-date with important events. Staff understand the importance and therapeutic value of residents having contacts with family and friends. However residents receive visitors at their discretion and the staff are keen to put residents’ welfare first. The menus are varied. The meals are balanced and nutritious and cater for varying cultural and dietary needs of individuals. Residents’ comments about the food were variable; some said it was very good, whilst others felt it varied. Care staff are sensitive to the needs of people in the home who require assistance with eating and drinking. They also pay particular attention to monitoring people’s weight loss. Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. People living in the care home will have their concerns listened to and are protected by the home’s response to complaints and potential abuse. EVIDENCE: Complaint records were examined and staff gave feedback about their responsibilities in relation to potential abuse. Two recent allegations regarding the vulnerability of one resident and poor practice by staff were discussed with managers. Comments received during the inspection process were: • “If we have any worries about Mum they are dealt with swiftly.” • “I have not felt the need to complain. Any issues I have are resolved directly with the managers/staff”. • “We have made two official complaints of which one was kept on file.” • “Usually the home responds appropriately when concerns are raised.” Complaint investigation is thorough, and are carried out by appropriate personnel. The manager is consistent in reporting untoward incidents that happen in the home. Reports produced for the Commission, and those carried out internally, are comprehensive. They clearly show how investigations have been carried out, and provide supporting evidence for conclusions. Where Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 17 elements of complaints have been fully or partially substantiated appropriate remedial action has been taken. There is a current internal investigation by the provider into concerns raised by a letter sent to Care UK by a person who did not want to be identified. The same person has also contacted the Adult Protection Co-ordinator for London Borough of Islington. The provider has organised a representative of Care UK to interview the staff group. As this is still on going no conclusions have been reached. The staff in the home are keen to co-operate with this investigation. Overall the service intends to send out clear messages that poor practice is not tolerated. The home has a copy of the Local Authority policy and procedure on the protection of vulnerable adults, which is linked into their own in-house document. Feedback from staff is that they have unlimited access to polices and procedures and receive copies as part of their induction. The manager has demonstrated through her own practice that she understands the Local Authorities’ role as the lead agency. Staff training records includes information about recent and ongoing training on adult protection. Feedback from staff shows that they are clear about their responsibilities to report any suspicions to their managers. They were also clear that they could contact social services and the Commission. Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 18 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 & 26 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live a well-maintained environment, which is decorated and furnished to a good high standard. Specialist aids and adaptations are available which are appropriate to meet the specific needs of the people who live there. EVIDENCE: The home was toured, including visiting a sample of bedrooms on each floor with the permission of residents. The manager has reported any repairs e.g. delays in repairing the service lift and a recently flooded bathroom. The home offers a variety of places for residents to sit. Furnishing and decoration are of a good standard, and any repairs that are needed are carried out promptly. There is access to outdoor seating areas. Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 19 All bedrooms are ensuite however communal toilets. There is full disabled access, including two lifts, one passenger, and one service. In addition to the ensuite faculties there are also showers and an assisted bath. This enables the home to meet a range of personal care needs, and the preferences of residents. On the day of the unannounced inspection the home was clean and odour free, and the domestic staff were observed to be very diligent in carrying out their duties. Feedback from people living in the care home is that the home is always fresh and clean. Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. The home has a staff team, who are trained and competent to do their jobs. EVIDENCE: Residents were asked for their views, staff were observed carrying out their duties, and training records were examined. An afternoon hand over meeting was attended and a separate group discussion held with staff. Staff rotas were checked. • • • • • • “Overall I feel the service is extremely good with staff being professional, friendly and helpful. Things have been better than I had dared to hope.” “Need to try and keep more permanent staff.” “As a visitor 3 to 4 times a week, I naturally have an insight as to how the staff look after people. I really do feel that they do a wonderful job in all respects.” “ Yes – standard of care is generally good but it can depend on the staff on duty.” “Need to try and keep more permanent staff”. “Usually the care meets the needs of my relative but it can depend which members of staff are on duty.” Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 21 Feedback from staff shows that they clearly know the needs, and wishes, of each resident. This includes the level of independence and privacy that each person wants. It is a very stable staff team, and those spoken to enjoyed working at the home. There is a very clear staffing structure with a manager, deputy, staff nurses, team leaders and carers providing personal care. There are also dedicated administrative, catering and ancillary staff. There has been a mixed response in respect of staffing levels. The current levels have been set as part of contractual agreements with the London Borough of Islington. These are satisfactory although unexpected staff absences can have an affect on the daily routine. Residents were complimentary about the staff. The interactions observed during the visit were both professional and caring. Staff gave feedback about their recruitment process. This is a thorough and robust procedure and matched the records seen in staff files. The home is working towards creating a stable staff team. Feedback from staff and records confirmed that they receive induction as well as regular training. Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. 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, in the interests of service users. The health, safety, and welfare of service users are promoted and protected. EVIDENCE: Residents, relatives and staff gave their views on the management and running of the home. All described a well run home, in the best interests of the people who live there. The manager has the required qualifications and experience and is competent to run the home. She was described as “very good”, “nice” and “approachable” as well as “exactly what the home needs.” Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 23 The manager makes regular personal rounds of the home to get feedback from both staff and people living in the home. She has a clear understanding of the key principles and focus of the service based on Care UK’s operational and business plan. Working in partnership with the London Borough of Islington, the home provides value for money. The manager returned the Annual Quality Assurance Assessment (AQAA) and it contained clear and relevant information that is supported by a wide range of evidence. The AQAA addresses the strengths of the service and identifies areas for improvement. Feedback from people using the service and from other stakeholders is obtained in a variety of ways. This has led to improvements in the service. The manager has addresses equality and managing diversity within the home. This is supported by a specific policy and within an equal opportunities framework. Wheelchair users have full access. Assessments and care plans include cultural and religious identification. Dietary requirements are met for people who are diabetic, vegetarian, soft diet, nutritional supplement and cultural needs. The menu is designed through consultation with relatives and service users ensuring cultural needs are catered for. Specific equipment to deal with complex physical disability is made available. All areas within the home comply with the Disability Discrimination Act requirements. The home has a clear health and safery policy and has a consistent record of meeting relevant health and safety requirements. Staff recive tarining and feedabck shows that they are fully aware of their role and responsibilities in maintaining a safe environment. A sample of health and safey records were looked at and these were found to be up-to-date and accurate. Safeguarding is given a high priority. The service is keen to learn from untoward incidents however people are encouraged to manage their own money where possible. Where the person is supported to look after their money, then clear and accurate records are mainatined. Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X 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 X X X X 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 Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement People who live in the home should have their personal preferences reflected in their care plans. People who live in the home are being supported to express their wishes for end of life care and dying. This information needs to be recorded in detail and reflect the religious and cultural preferences. Timescale for action 30/09/08 2 OP11 12(2) & (4)(a) 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Muriel Street Resource Centre DS0000054457.V367811.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Muriel Street Resource Centre DS0000054457.V367811.R01.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. 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