Care Home: St Mary`s Mount

Similar services:

• Maple Lodge
• Heathlands
• Aston Court Nursing Home
• Breme
• Ravenhurst
• Bank House
• Inspirations
• Ashcroft Hollow Nursing Home

What has improved since the last inspection? The service has addressed the requirements we made at our last visit. Assessments for the use of bedrails are completed and staff are making sure that the safety of bedrails are checked. This is making sure that people are being kept safe. Staff are trained in spotting signs of possible adult abuse and know what to do if they feel someone may be being abused. This will make sure that any abuse is identified and acted upon All staff now to have the pre employment checks they need before they start work. This includes Criminal Records Bureau and Protection of Vulnerable Adult checks and checks on referees. This will improve the safety of people that live there. Since we visited last time the service has increased the level of social activities available to people. They have also started to arrange trips out. This will improve the quality of life people experience. Improvements have been made to the accommodation. Seven bedrooms have been upgraded and provide ensuite accommodation. What the care home could do better: We have made no requirements at this inspection. We have made some recommendations. The service should ensure that some areas of the plans are more detailed particularly for those people with mental health needs. This will make sure staff have more information on how to respond to people`s needs. We feel that the service could develop more the social care provision for people that have mental health needs and cannot or choose not to take part in group activities. We also recommended that the service makes sure that there are always enough staff on duty to meets people`s needs promptly.St Mary`s MountDS0000005003.V374868.R01.S.doc Version 5.2 Page 7 Key inspection report CARE HOMES FOR OLDER PEOPLE St Mary`s Mount Holly Road Uttoxeter Staffordshire ST14 7DX Lead Inspector Jane Capron Key Unannounced Inspection 6th April 2009 09:30 DS0000005003.V374868.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. St Mary`s Mount DS0000005003.V374868.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address St Mary`s Mount DS0000005003.V374868.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Mount Address Holly Road Uttoxeter Staffordshire ST14 7DX 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) 01889 562020 01889 562020 stmarysmountenquiry@tiscali.co.uk HAS Careplus Limited Manager post vacant Care Home 30 Category(ies) of Dementia (14), Old age, not falling within any registration, with number other category (30), Physical disability over 65 of places years of age (7) St Mary`s Mount DS0000005003.V374868.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 30 Physical disability - over 65 years of age (PD(E)) 7 Dementia (DE) 14 The maximum number of service users who can be accommodated is: 30 9th April 2008 2. Date of last inspection Brief Description of the Service: St. Marys Mount stands in its own grounds within half a mile of the centre of Uttoxeter where a wide range of local shops and services can be accessed. There is a town bus route passing the gateway, and the railway station is about a mile away on the other side of the town centre. The service is registered to care for a maximum of 30 older people, 14 of who may have dementia care needs and seven a physical disability. There are 28 bedrooms, 26 of which are for single occupation, and two of which are shared. The service is in the process of altering the accommodation to provide all single bedrooms and to provide rooms with ensuite facilities. There is separate smoking area for residents. The present scale of fees is £393-£450 but people may wish to obtain more up to date information from the service. Other additional costs would include hairdressing, private chiropody, personal toiletries and newspapers. St Mary`s Mount DS0000005003.V374868.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 star. This means the people who use this service experience good quality outcomes. This inspection took place over a seven-hour period and the service did not know we were visiting. This information used as part of this inspection included: • The annual quality assurance assessment (AQAA) that was sent to us by the service. 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. • Four surveys provided by a people living at the service. • Information from health care staff that support people living at the service. • Information we have about how the service has managed any complaints and safeguarding incidents • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • Discussions with staff and the manager • Discussions with people living at the service • Observation of staff supporting people • An examination of records What the service does well: People tell us that the service has made improvements to the care it provides. Comments include ‘care has improved tremendously and manager deserves praise for this’. People feel that they are having their care needs met. People receive health care from the doctor or district nurse when they are ill, have eye and have dental checks. People have their personal care needs met and they are treated with respect. Staff are developing their knowledge to provide improved support for people with dementia care needs. People have the chance to take part in a range of activities including going out on trips. The menus have changed and people like the meals. A varied menu is provided and people always have a choice. St Mary`s Mount DS0000005003.V374868.R01.S.doc Version 5.2 Page 6 The service provides good accommodation. Communal rooms are suitably furnished and decorated. Bedrooms provide people with suitable private accommodation. People can bring in their own possessions and make their bedroom their own. The service monitors and reviews the care it provides taking into account the views of people that use the service, their relatives and professionals. A plan on how the service intends to improve is in place. The service is being well led. The recently appointed manager has made a number of changes and this has improved the service. What has improved since the last inspection? What they could do better: We have made no requirements at this inspection. We have made some recommendations. The service should ensure that some areas of the plans are more detailed particularly for those people with mental health needs. This will make sure staff have more information on how to respond to people’s needs. We feel that the service could develop more the social care provision for people that have mental health needs and cannot or choose not to take part in group activities. We also recommended that the service makes sure that there are always enough staff on duty to meets people’s needs promptly. St Mary`s Mount DS0000005003.V374868.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. St Mary`s Mount DS0000005003.V374868.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 St Mary`s Mount DS0000005003.V374868.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that are considering using the service are provided with information about what the service offers so that they can decide if the service can meet their needs. People can be assured that an assessment of their needs is completed so that the service can be sure it can meet their needs. EVIDENCE: The service’s Annual Quality Assurance Assessment (AQAA) states that a full needs assessment is carried out by a senior member of staff to ensure that the service can fully meet a prospective person’s needs. Looking at a sample of files confirms that assessments are completed before people are admitted to the service. The assessments contain information about people’s physical and mental health, their personal care including their dietary needs and communication. The assessment also covered people’s social care needs including family relationships and spiritual needs. St Mary`s Mount DS0000005003.V374868.R01.S.doc Version 5.2 Page 10 Since we had visited last time the service has updated its service user guide. It contains all the necessary information so that people know what the service offers. This includes photographs and the views of people living there. It is available in large print. St Mary`s Mount DS0000005003.V374868.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be assured that the service will meet their personal and health care needs. The service’s medication arrangements are making sure that people that live there receive their medication as prescribed. EVIDENCE: The AQAA tells us that each person has an individual care plan that includes a range of risk assessments and this is reviewed regularly with the person concerned and their relatives. Examination of a sample of care plans confirms that everyone has a plan in place and these are person centred. Plans cover the areas of health care needs, medication, personal care, mental health and social care needs. Plans are evaluated monthly. The manager did tell us that she still intends to develop the plans further. We did feel that that the areas relating to mental health could be further developed to give staff a better understanding of how to respond to people when they are for example agitated or showing aggressive behaviour. Files show that regular assessments are completed in St Mary`s Mount DS0000005003.V374868.R01.S.doc Version 5.2 Page 12 respect of people’s skin integrity, their nutritional health and mental and physical health. Where people are using bedrails, assessments are completed and discussions held with relatives to gain their views. Checks on the safety of bedrails are completed. Moving and handling assessments are in place as well as fall risk assessments. When we spoke to staff they could tell us about people’s needs and the action they should take to ensure they were met. One person whose file we looked at needs to be supported to maintain their skin integrity and staff could tell about the care they need. Records and observation show that this person has the necessary equipment such as a pressure relieving mattress and cushion provided. We also saw that staff are keeping records relating to their fluid and food intake. This person is also being moved regularly to ensure they do not remain in the same place too long thereby putting too much pressure on their skin. Another person needs to be supported to get dressed but can shave with some support. Staff are aware of this and provide the support for this person to shave themselves. We also saw that daily records are being kept. This shows that in one instance staff had identified that a person was more agitated than usual and following this up resulted in it being found that they had a urine infection. Once this was addressed their condition improved. Records confirm that people have dental and eye checks and that a chiropodist now visits the service. Our surveys confirm that people that live at the service and their relatives feel that the service is able to meet their needs. Comments include ‘very good attention’. One relative said that their relative ‘always appears well cared for and I am informed about her condition and any changes’. Surveys from health care staff are also positive commenting on improvements within the service. One said it is ‘much better than in the past- new care manager has made huge improvement’ and another said ‘home is much cleaner, calmer and better organised. Staff and residents seen happier since new care manager’. One person did comment that staff could have more knowledge about managing diabetes. We saw that training in diabetes was taking place on the day we visited. People are having their privacy respected and their dignity promoted. People are suitably dressed and have their hair and nail care attended to. All bedroom, toilet and bathroom doors are lockable. We saw staff knocking on bedroom doors to gain permission to enter. We also saw that staff speak to people in a respectful manner and that people are called by their preferred name. We saw staff that staff are bending down so as to be on the same level when speaking to them. Feeding of people is being completed in a respectful and sensitive manner with the staff sitting next to person and explaining what they are doing and telling them what the food was. Staff feed people at their pace and are not being distracted to do other tasks or to speak to other people or staff. Staff spoken to are aware of how to promote people’s dignity and St Mary`s Mount DS0000005003.V374868.R01.S.doc Version 5.2 Page 13 privacy for example keeping people covered when completing personal care tasks. We checked the way the service is managing people’s medication. The service is using a blister pack system. Records are kept of medication received and audits on medication are completed. We checked the records of two people’s medication and these show that they are receiving the medication as prescribed. The medication administration records are properly completed and there are no gaps. Protocols for PRN medication are in place. We did advice the service to look at providing more detail as this would ensure that all staff are fully aware of when to administer PRN medication. The service has put in place a system for the review of everyone’s medication and this has led to some people having their medication reduced. One person that has difficulty in taking medication in pill form has been changed to having their medication in a liquid form. This is proving to be successful and this person is now having their medication as prescribed. The service has no controlled medication. Staff are trained in managing and administering medication. St Mary`s Mount DS0000005003.V374868.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that the service will provide a range of social activities but needs to ensure that these are also available for people with needs relating to mental health needs. People that live at the service have a choice of food. EVIDENCE: The AQAA states that service offers people choice and independence and provides a regular activities programme. The service also tells us it offers a flexible routine giving people freedom to choose when to get up and where to have their meals. We saw that an activity programme is in place showing an activity every day. These include bingo, watching old time films, craftwork, and board games. People were playing skittles during our visit. Easter cards made by people living there are on show in the lounge. In the afternoon one person was reading a newspaper and another reading a book. An organist and someone that shows films of the countryside provide entertainment and relatives are invited to these sessions. People tell us that the service also arranges trips out. The previous night a group went attended a proms evening in Uttoxeter. Trips to a local farm and to Blackpool are being arranged. The service does not St Mary`s Mount DS0000005003.V374868.R01.S.doc Version 5.2 Page 15 have an organised religious service but religious leaders visit to see individual people. A number of people with mental health needs have difficulty in joining in with organised activities and the service needs to look at how it can provide more social stimulation for these people. Surveys provided by the service as part of their monitoring service confirm that relatives feel welcomed to the service. Comments include service ‘friendly and good’ and ‘warm, friendly’. During the day a number of relatives visited and we noticed that there is a friendly relationship between them and the staff. Looking at the visitor’s book confirms that people that live there have lots of visitors. Staff tell us that one person’s relative visits four times a week and helps to feed them. Also whilst we were there a relative rang to arrange to take their relative out. The service tells us that it promotes people’s choices and autonomy. People are provided with choices over meals. We saw that two people did not want the meal on offer, one wanting a banana and the other cornflakes. Both received these. We spoke to people and they told us they could get up when they want and spend time in their bedroom or the communal rooms. Looking in people’s bedrooms shows that people can bring in their own possessions. Staff also told us about how they encourage people to make choices. The manager tells us that they have altered them menus to make them more nutritious. We received positive comments from people that answered our surveys. Menus show that people are able to have a choice of meals. Breakfast during the week is porridge, cereals and toast and at weekends there is a choice of a hot breakfast. The main meal is taken at lunchtime and on the day of the inspection was either corn beef hash or meat and potato pie with vegetables followed by syrup sponge and yoghurts. Tea consists of a jacket potato with a choice of fillings, sandwiches and cakes. Supper is available for people that want it. Food is also available throughout the night. The chef told us that he would always try and respond to people’s specific requests. Meals can be provided in a soft form and we saw this was well presented. People are provided with good-sized portions. Special diets can be provided for. We saw that some people needed feeding and this was completed in a sensitive manner. People are able to eat their meals in the dining room or in their bedroom. St Mary`s Mount DS0000005003.V374868.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that if they have any complaints these will be acted upon. People are protected by the staff’s knowledge of safeguarding issues. EVIDENCE: The AQAA tells us that the service’s complaints procedure is displayed in the service and is available in a large print version. It also states that the service takes immediate action on any complaint received and that accurate records are kept showing any action taken. The surveys we received say that they know about the procedure and how to make a complaint. They also report that staff listen to them and act on what they say. We saw that the procedure was displayed in the service. We also saw that the service is keeping records of any complaints made and these outline actions taken to respond to complaints. The service has received two complaints that have been addressed. We, the commission, have received no complaints since we visited the service last. The service tells us that it works within the locally agreed safeguarding procedures and that all the staff have received safeguarding training. We saw records that confirm that this training has been provided. Speaking to a sample of staff confirms that they are aware of signs of abuse and know how to respond if they have any concerns. The manager was aware of the Interagency Safeguarding Procedures. There have been no safeguarding incidents since we visited last. St Mary`s Mount DS0000005003.V374868.R01.S.doc Version 5.2 Page 17 St Mary`s Mount DS0000005003.V374868.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,25,26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that live at the service have private and communal accommodation that is suited to their needs and can be assured that procedures are in place to control the spread of infections. EVIDENCE: The AQAA states that the service provides a safe and secure environment for the people that live there. They also say that improvements have been made to the service including redecorating and upgrading some of the bedrooms to provide ensuite facilities, buying new easy chairs and new hoists and building a sensory garden. The service is provided in a large old house with a downstairs extension. It is set in large grounds mainly laid to lawns. The service provides good accommodation. There are two large lounges and a small sitting area and a separate dining room. One lounge and the dining room are of a very good St Mary`s Mount DS0000005003.V374868.R01.S.doc Version 5.2 Page 19 standard of décor and the second lounge is due to be redecorated in the coming weeks. The service provides sufficient toilets and bathrooms having an assisted bath and a level access shower. Several of the toilets and bathrooms have been redecorated and upgraded. Currently the service offers all single bedrooms but two rooms can be used as two bedded rooms. All the seven upstairs rooms have ensuite facilities and all others have a washbasin. The service has long term plans to provide all ensuite accommodation. Inspecting a sample of bedrooms shows them to provide suitable private accommodation. Bedrooms are lockable, they all have adequate storage space and provide seating. People can bring in their own possessions and items of furniture. Bedrooms are well personalised and one room seen has a settee, chair and dining table brought in by its occupant. The service is starting to alter the environment to help people with memory loss to be able to orientate themselves to the premises. Pictures are on bathrooms and toilets and some bedrooms have pictures on their doors to help people know which is their bedroom. Plans are in place to develop this further through for example having memory boxes. The service’s AQAA says that it is clean and hygienic. People in our surveys say that the service is ‘always’ or ‘usually’ clean and fresh. Information from the service’s own surveys say that they feel that the cleanliness has improved. One reported that the service is ‘cleaner, brighter and smells fresher’. The service has cleaning schedules in place and the domestic staff now work more flexibly to meet the needs of the people living there. Most of the staff have completed training in infection control and we saw that staff use gloves and aprons when supporting people with personal care. The service also has handwashing gel in the foyer for visitors to use to reduce the risk of infections. St Mary`s Mount DS0000005003.V374868.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that use the service are supported by staff that are trained and properly recruited. The service provides adequate numbers of staff to provide people with the support they need. EVIDENCE: The AQAA states that the service employs sufficient staff to meet people’s needs and provides staff with relevant training. It also says that it operates a thorough recruitment procedure. Staff tell us that the staffing levels allow for four staff on duty during the morning, three in the afternoon and evening and two overnight. The manager is included on the rota several days a week and she was working as a care staff member on the day we visited due to staff sickness. She said she did this because she wanted to work alongside people to show them the standard of care she expected. Examination of the rosters shows that there have been occasions when this level was not met. When we raised this with the manager she told us that the service is now fully staffed and they are able to maintain the necessary levels to make sure that people’s needs are met. We did see sufficient staff on duty during the inspection. Comments from our surveys tell us that staff are usually available when they need them. People we spoke to said that they liked the staff with comments made including ‘good staff’. St Mary`s Mount DS0000005003.V374868.R01.S.doc Version 5.2 Page 21 Talking to staff and an examination of the records shows that staff are receiving relevant training. Recent training has included safeguarding, infection control, dementia care and challenging behaviour. Notices on the wall show that further training is planned such as diabetes, medication and further infection control. The service tells us that five people have obtained an National Vocational Qualification in care and a further eight are close to completing the qualification. When we spoke to staff they were able to describe how they were meeting specific people’s needs. Examination of a sample of staff files confirms that the service is seeking the necessary pre employment checks. All the four files we checked contain both a Criminal Records bureau (CRB) and Protection of Vulnerable Adults (POVA) check. Staff without a full CRB check are being supervised by a senior staff member. All files contain two references including the previous employer, a health check and confirmation of identity. St Mary`s Mount DS0000005003.V374868.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the service can be assured that the service is being run in their best interest and that the staff’s practices are protecting them. EVIDENCE: The AQAA tells us that a new manager is in post and that she is a qualified and experienced manager. It also tells us that people that live there and staff are involved in the running of the service and are encouraged to make suggestions to improve the service. A new manager has been working at the service for five months. She is not yet registered with the commission but has started the process. She is a registered nurse and has previous experience of managing a care service. Since moving to the service she has put in place a range of changes to St Mary`s Mount DS0000005003.V374868.R01.S.doc Version 5.2 Page 23 improve the service. These include ensuring staff have the training to undertake their role, improving the care plans, changing the menus and developing the social side of the service. We have received positive comments about the effect the new manager has had on the service. Our surveys from one person that lives at the service said ‘since the arrival of the new manager the home is improving greatly’ and a health care professional said ‘care has improved tremendously’. The service provided us with their self-assessment document when we asked for it. It gave us information about the service, the improvements they have made and the improvements they intend to make over the next two months. The service undertakes a range of audits to monitor the service. These include checks on safety, medication and the environment. Surveys are also sent by the service to people that live there, relatives and professionals. These show positive responses including ‘warm, friendly, acted in professional manner, ‘communication is very good’ and ‘residents appear very happy’. An improvement plan is in place showing areas that the service intends to develop. The service tells us that it has regular staff meetings to gain the views of the staff. The service only looks after one person’s money and a check on this showed it to be managed correctly. Records of expenditure with accompanying receipts are kept. The amount in cash corresponded with the written records. The information that the service sent us tells us that the service maintains checks on equipment. Checking a sample shows that fire checks are completed including the fire alarms, emergency lighting and fire equipment. Regular fire drills are held. Talking to staff and an examination of staff records shows that staff are trained in health and safety issues including manual handling, fire, infection control and food hygiene. St Mary`s Mount DS0000005003.V374868.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X X 3 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 2 X 3 X 3 X X 3 St Mary`s Mount DS0000005003.V374868.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. 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 OP7 Good Practice Recommendations Where people have mental health needs the care plan be fully developed to identify how these needs should be responded to. This will make sure that staff have all the information to meet people’s needs. To develop further social stimulation for people that cannot join in with group activities for example people with dementia. This will improve people’s lifestyle. The service should ensure that there is always adequate staff on duty in order that people’s needs are met promptly. 2. OP12 3. OP27 St Mary`s Mount DS0000005003.V374868.R01.S.doc Version 5.2 Page 26 Care Quality Commission West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway, Birmingham B1 2DT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. St Mary`s Mount DS0000005003.V374868.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. 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!