Care Home: St Mary`s Home

Similar services:

• Ashlong House
• Norbury Crescent (30)
• Edenvale
• Wadham Avenue
• Chatsworth Care - Dawson House
• Cowden Road, 52 - 54
• Chatsworth Care - Tudor Lodge
• Foxley Lane (121a)

What the care home does well The management approach continues to ensure that the service is run in the best interest of the people who use the service. People are supported, where able, in developing independence skills and contribute their ideas to the running of the home. Staff have a very good awareness of peoples needs and are committed to providing a person centred service. Any changes in peoples` needs are effectively identified and addressed. Individuals are encouraged to participate in activities of their choosing and there are opportunities for people to develop their skills and abilities. Staff work well with other professionals involved with the people who use the service. What has improved since the last inspection? Full assessments of peoples needs are obtained prior to admission to the home. The home ensure that all required checks are obtained prior to new staff starting to work in the home. Some people in the home receive good support to access services from outside the home. What the care home could do better: Risk assessments must be signed and dated by staff involved in drafting them, as well as the resident, where able. Hot water checks must be carried out weekly. The testing of the fire alarm system must also be carried out weekly and a record maintained. CARE HOME ADULTS 18-65 St Mary`s Home Roehampton High Street London SW15 4HJ Lead Inspector Davina McLaverty Unannounced Inspection 10th December 2007 10:00 St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Home Address Roehampton High Street London SW15 4HJ 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) 020 8788 6186 020 8788 1057 www.ftf.org.uk The Frances Taylor Foundation Ms Lisa Dowling Care Home 42 Category(ies) of Dementia - over 65 years of age (13), Learning registration, with number disability (42) of places St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2006 Brief Description of the Service: St Marys is a care home for 42 adults with a learning disability. The home is located on the High Street in Roehampton, close to shops, pubs, the post office and other amenities. It is owned by The Poor Servants of the Mother of God, a voluntary organisation and is managed by The Frances Taylor Foundation. A copy of the last inspection report is displayed in the home. The current weekly fees that are charged at St Mary’s start from £489.25 to £1,378.24. St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day and lasted six hours. A number of records were examined, which included staff records, care plans, medication records, health and safety records, and the record of complaints. A tour of the communal areas of the premises was seen as well as some of the bedrooms. Six staff, as well as the manager were spoken with. The manager has worked at the home for a long time and knows the residents’ needs well. Prior to this inspection taking place the Manager completed an Annual Quality Assurance Assessment (AQAA), and evidence from this was used to help form some of the judgements in this report. Twenty survey forms were sent direct to the home for the manager to forward to individuals residing there. Twenty surveys were also sent for staff to complete as well as twenty surveys for relatives. Six surveys were returned from relatives, ten from people living in the home and eight from staff. Nearly all responses in the surveys were positive, and have been used to form and support some of the judgements made in this report. Communication with the majority of people living in the home was not possible due to the level of their learning difficulties, although observation with staff and with each other was seen. Six people living on the third floor were spoken with and their views are referred to in the main body of this report. The inspector was made welcome during the visit and wishes to thank all those who gave their views about the home. What the service does well: The management approach continues to ensure that the service is run in the best interest of the people who use the service. People are supported, where able, in developing independence skills and contribute their ideas to the running of the home. Staff have a very good awareness of peoples needs and are committed to providing a person centred service. Any changes in peoples’ needs are effectively identified and addressed. Individuals are encouraged to participate in activities of their choosing and there are opportunities for people to develop their skills and abilities. Staff work well with other professionals involved with the people who use the service. St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 4 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. There is clear information about the home, which will help potential people and their relatives/ advocates understand what the service provides. Assessments are completed before people move into the home, in order to make sure that their individual needs can be met. EVIDENCE: There is a comprehensive Statement of Purpose and Service User Guide, which includes information about the home and how to make a complaint. There is a comprehensive assessment procedure in place, which includes several visits to the home for the prospective person and their representative. Five files were examined, which included three new residents and appropriate documentation was seen on the files. In discussion with staff they confirmed that prior to admission, visits to the home took place to in order to give the person and their representative the opportunity to see the home and meet St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 9 other people living there, as well as to enable staff to complete their assessment and ensure that the persons needs can be met. After admission the home has a 90 day getting to know you period, when a meeting will take place. If the person is not happy or the staff feel that they cannot provide the care needed an alternative placement would be sought. St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 & 9 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home records peoples’ needs and strengths and works with them to identify goals that are important to them. People receive good support to make informed choices about their lives as well as being consulted about issues that affect them in the home. The home supports people in taking manageable risks. EVIDENCE: The inspector was informed that all people residing in the home have a care plan. Five were sampled and found to be person centred and provided sufficient information about how people’s needs are to be met. The quality of recording on the care plans seen on the whole was good, recording detailed St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 11 information about individual strengths, needs, preferences and goals. Reviews were also seen to be taking place. Risk assessments continue to address areas of risk such as going out, selfadministration of medication, diet and food intake, sexual relationships, use of cot sides and safe use of hot water. Regular reviews take place. However, risk assessments must be signed people involved in agreeing the risk. Where the person concerned is involved they must also sign their risk assessment. People where able are supported to make choices about their daily lives and are consulted about decisions that affect them. People living on the top floor gave various examples to the inspector of decisions they had been involved in e.g. choosing furniture for the lounge, what activities they wished to go to. The home also consults significant others, such as family members and health care professionals, about peoples care where necessary. All six people spoken with confirmed that they chose how they spent their day, what time they got up and went to bed. St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, 16 & 17 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Some people who live at the home are given lots of opportunities to take part in a wide range of activities at the home and in the community. People are supported to develop and maintain relationships with their families and friends. People enjoy the food provided by the home and some people are involved in shopping and planning their menu. EVIDENCE: The inspection provided evidence that individuals are enabled to live their lives at their own pace and with the support of staff on duty. Individuals were in and out of the home participating in activities of their choice. One person spoken St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 13 with said that they attended Share Community and was involved Maths and English classes, as well as in computing where they received and sent e-mails to various people which they enjoyed doing. Others spoke of trips out shopping, to church, to lunch, and to the hairdressers. Some people said that they enjoyed visiting friends, one person informed the inspector that they were going to spend Christmas with their aunt and was looking forward to it. Staff reported that some people attend the homes day centre whereas others will access places in the community. Daily routines of some people who live at St Mary’s are fluid, in that they could also change at short notice if that’s what the person wanted. Several people spoke of the various activities and events that took place in the home e.g. regular mass, barbecues, outings, and holidays as well as their access to local facilities e.g. hairdresser’s, the library, pubs and restaurants. Contact with families varied but was encouraged and supported with individuals living in the home. Interaction between staff and residents was positive during the inspection. Resident’s wishes and needs are identified in their individual plans. Staff used appropriate forms of address when speaking to people in the home. People’s rights and responsibilities are recognised in their daily life. Consideration is now clearly being given to people’s capacity under the Mental Capacity Act and the manager spoke with the inspector, whereby as assessment had been carried out on a person residing in the home as to whether they had capacity to make a decision. From the relatives surveys received the inspector formed the view that they were happy with the care their relative received. With comments such as “When I visit my relative they seem very happy”, another “ I know very little about the home but my sister has lived there for well over 50 years and is extremely happy and very well looked after” and “Carers are in contact with me to arrange holidays etc”. One relative stated that they felt staff should wear identification badges. The manager stated that there is a staff identification board, in the home where relatives can see the names of staff but she would give consideration to this request and encourage staff to introduce themselves to visiting relatives. People spoken to on the top floor were very positive about the food and the choices offered. They all stated that they could more or less do what they like and can eat the food they enjoy. During the inspection people were observed to make a drink or snack when they wished. Records of menus are kept and these showed that a suitable range of food is available for people to enjoy. People on the other floors are more dependent, however, three of the people spoken to were also positive about the food. Staff spoken to on the ground floor was aware of peoples likes and dislikes concerning food and tried to ensure that people were given meals that they would enjoy. Several people are St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 14 supported to eat and have their meal prepared in a way that they can safely eat and enjoy. People, if able are encouraged to participate in the preparation of some meals. Everyone spoken with were very positive about the home with comments such as “ it’s a marvellous place”, “ I wouldn’t live anywhere else, staff are so kind and help me do the things I cannot do on my own”, “ I have lived here for 55 years and I have seen so many positive changes, this place gets better and better I am very happy living here”. St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home support people to maintain good health. Changes in peoples needs are effectively identified and addressed The home works co-operatively with other professionals in delivering people care. An appropriate medication system is now in place. EVIDENCE: Staff were observed to treat people in the home with respect. People are able to make choices about how they prefer to live and receive support, for example, how they have their rooms and what time to get up and go to bed. The staff team reflects the cultural background of people who live there. St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 16 All people are registered with a local GP, opticians and dentist and are supported as required to attend appointments. The home has input from Wandsworth Community and Assessment team and work very much in partnership with various professionals to best meet the assessed needs of the people living in the home, some of whom have quite complex needs. As stated in the previous inspection report personal aids and equipment are available and well maintained to support people in daily living. Carers provide various degrees of support to people in respect of personal care, depending on individual abilities. People are encouraged to do as much for themselves as possible and again some people stated this to the inspector. There is an appropriate medication policy and procedure in place and staff receive training before being authorised to give medication. All medication coming into or leaving the home is recorded. Since the last inspection the home has changed suppliers of medication to Boots and most medication is now provided in blister packs, which the manager and staff state is much easier to administer. However, medication, which cannot be put in a blister pack, is stored in a large box in a locked cupboard, due to insufficient space to store separately. The home was advised to discuss the suitability of storing medication like this at Boots next audit visit. St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Staff are well informed about adult abuse issues, which helps to protect people living in the home. Staff listens to people’s views with appropriate action being taken. EVIDENCE: An appropriate complaints procedure is in place. People confirmed verbally and in their surveys that they have a copy of the complaint procedure and that they knew how to complain if they needed to. People spoken with said that they were well treated by staff and that they felt listened to. One person spoke of a recent complaint they had made against a staff, which they said had been satisfactorily addressed. The complaints book was examined however; this complaint was not seen in the book. In discussion with the manager she confirmed that it had been investigated and would ensure that details were recorded in the complaint log. Staff must ensure that all complaints are logged in the complaint book detailing the outcome. The home works within the Local Authorities policy on Safeguarding of Vulnerable Adults and all staff attend training in this area. Staff spoken to St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 18 were aware of safeguarding procedures as well as the organisation’s whistle blowing policy and said that they did not have any concerns or issues. There was evidence that the home worked in partnership with the local authority regarding a safeguarding issue and appropriate steps were taken by the home. St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,29 &30 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home is safe and well maintained with communal rooms being comfortable and homely. Resident’s bedrooms reflect their individual preferences. Specialist equipment has been installed where necessary. The home is clean and hygienic. EVIDENCE: The home is situated in a pleasant residential area in Roehampton and has good access to local community facilities, open spaces and public transport networks. St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 20 The home provides comfortable and well-maintained accommodation to the people residing there. CCTV is available with an entry phone system. Bedrooms were seen to be personalised. Various rooms seen had specialised equipment e.g. raised beds, ripple mattresses. The home has a number of double bedrooms and the inspector was informed that the home wants to reduce the number of shared rooms. As stated earlier, the home is situated over four floors. Each unit has its own character, which reflect the needs and likes of the people residing there. Separate lounges and kitchens are available on each floor. Residents on the top floor are more independent and spoke of their involvement in choosing what went into the lounge e.g. pictures, ornaments etc. On the day of the inspection some of the people residing on the top floor were putting up their Christmas decorations. The bathrooms and toilets were also fitted with appropriate aids and adaptations to meet the needs of the people who use the service. Bathrooms are sufficient in number. At the last inspection the home was in the process of converting the treatment room and bathroom on the ground floor into one large bathroom with a Parker bath and tracking hoist which would better meet the needs of the wheelchair users. This has now been completed. The manager said that she is planning to have a second parker bath in the home as well as increase the number of walk in baths /showers which will help to maintain peoples independence with personal care. A large laundry with appropriate washing and drying appliances is available on the ground floor. There are also washing and drying machines on each floor which some of the residents can use on their own. A large art room and multi-sensorial room is also available in the home. There is also a separate well-equipped day centre, which is used by some of the residents as well as by people who live in the community. A large well maintained garden with appropriate seating is available. The home was found to be clean and tidy on the day of the inspection. Relatives in their surveys also made reference to the cleanliness of the home. St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 & 35 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. There are enough staff to meet the needs of the people residing in the home. Staff are appointed following an appropriate recruitment and selection procedure. Staff have access to training and support. EVIDENCE: The home operates with three staff on each floor with the exception of the third floor, which has one or two, as the people living there are more independent. At night there are two waking night and one staff asleep but on call. Additional staff may be rostered depending on what activities are taking place and what some individuals may want to do. Staff spoken with stated that they felt that sufficient staff were on duty to meet peoples need and they confirmed that the manager is flexible and will increase staffing levels if need St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 22 dictates. Several staff spoke of good teamwork and spoke positively about their work at the home. One staff member in their staff survey said, “staff ratios are very good, however, with staff sickness it can be difficult at times, however, we have a good bank team and staff will always help out and do overtime when needed. We do not use agency staff which is good”. Staff also confirmed that the training was good and that it was appropriate to their roles. Mandatory training is updated as required. One staff in their questionnaire said that the induction “provides us with the knowledge we need to support people with a wide range of different needs. Another person said in their survey in response to the question regarding support, experience and knowledge stated “ If we are unsure we have a very good relationship with the local community team who will advise and provide training and support. We also have guidance from our operational policies and procedures as well as plenty of experienced staff to ask. The training here is very good and most staff have NVQ in care. Staff records provided evidence of a robust recruitment procedure and that the organisation carries out appropriate pre-employment checks on staff, including references and Criminal Bureau disclosures. This is significant improvement from last year. St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 &42 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home has an experienced manager. Staff support residents to contribute their ideas to the running of the home. A quality assurance system is in place, which seeks the views of stakeholders, relatives and people residing in the home. Systems are in place to ensure the health and safety of residents and staff. EVIDENCE: St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 24 The manager has worked in the home for many years and in various posts. Staff spoken to were positive about her management style and people residing on the top floor knew who was in charge and said that they liked the manager as she always listened to what they had to say. One staff member in their survey said, “ Lisa is very supportive and fair. She is readily available for advice and support with work concerns”. Another said “ We are all well supported by the manager and that the real underlying ethos of St Mary’s is Team work. The work is not very easy but the atmosphere of the place is very good”. The inspector found that there is a commitment to running the home to suit the needs of the people who live there and people’s views are regularly sought through the residents meeting. A quality assurance system is in place, which seeks the views of people living in the home as well as their relatives and other stakeholders. Questionnaires are sent out annually, on return they are collated and necessary changes made to practice. Policies and procedures are in place in respect of health and safety. A sample of records were examined which included the hot water tests and the testing of the fire alarms. Both these checks were found not to be taking place weekly as required. Other records examined included the landlord’s gas safety record, the five-year electrical installation certificate, the portable appliance test and servicing of the extinguishers and Fire Risk assessment of which all were found to be in order. St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? 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 2 3. Standard YA22 YA42 YA42 Regulation 22 17(2) 17(2) Requirement All complaints must be recorded in the complaints book. The hot water must be tested weekly and a record maintained. A written record is maintained of the weekly fire alarm tests. (Timescale of 31/08/06 not fully met) Timescale for action 10/12/07 10/12/07 10/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA9 Good Practice Recommendations Parties involved in the decision-making must sign risk assessments. St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Mary`s Home DS0000010230.V355073.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!