Care Home: St Marys Nursing Home

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What the care home does well St Mary`s Nursing Home provides people that use the service with a good standard of care. Care files for people that use the service contain a map of life; this includes information on school years, family, employment, hobbies, likes, dislikes and other important and useful information. This information is particularly important when caring for a person with dementia. Assessments and care plans examined contained excellent detail about the person including areas of risk and help needed to promote independence in each activity of daily living. 88% of care staff working at the home have achieved a minimum qualification of NVQ level 2 in Care or equivalent. In general people that use the service are happy with the care that they receive. Comments made included, "I find everyone to be caring and helpful" "They look after me well. Staff are kind and caring" "The girls are good they look after my every need" What has improved since the last inspection? Lots of thought has been put into the decoration of the dementia and mental health unit. One area of the unit is described as a holiday suite and is used to provide respite care. This part of the unit contains four bedrooms and has been decorated in a seaside theme. One corridor area has been developed as a sensory/tactile area for people who use the service to enjoy the experience of touch. This area of the home contains picture frames which have been filled with different materials that have different textures. There are also familiar objects such as bolts fixed to the walls. The manager said that people that use the service particularly enjoy this area of the home. The home has employed an activity co-ordinator to work thirty six hours a week. Activities taking place on daily basis include crafts, games and quizzes. Regular in house entertainment is provided. Singers come into the home frequently. The manager advised that activities take place both on the older persons unit and on the dementia unit. She said that both units do come together for activities particularly when there is a big event at the home. Requirements identified at the last inspection have been addressed. What the care home could do better: Staff records of recruitment and training are not up to date as required by regulation for the protection of people that use the service and for the effective and efficient running of the home. The manager has commenced a programme of supervision with staff working at the home; however this is not happening as often as it should be. The manager of the service needs to apply for registration with the Commission for Social Care Inspection. Regular competency checks should be carried out on those people who are responsible for administering medication to ensure that safe practice is being followed. CARE HOMES FOR OLDER PEOPLE St Marys Nursing Home 1 The Crescent Linthorpe Middlesbrough TS5 6SD Lead Inspector Katherine Acheson Key Unannounced Inspection 24th March 2009 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Marys Nursing Home DS0000000207.V374679.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Marys Nursing Home DS0000000207.V374679.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Marys Nursing Home Address 1 The Crescent Linthorpe Middlesbrough TS5 6SD 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) 01642 820851 01642 828754 www.bupa.co.uk BUPA Care Homes (GL) Ltd Care Home 40 Category(ies) of Dementia (19), Mental disorder, excluding registration, with number learning disability or dementia (19), Old age, of places not falling within any other category (21) St Marys Nursing Home DS0000000207.V374679.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP, maximum number of places 21 Mental disorder, excluding learning disability or dementia - Code MD, maximum number of places 19 2. Dementia - Code DE, maximum number of places: 19 The maximum number of users who can be accommodated is: 40 Date of last inspection 1st December 2006 Brief Description of the Service: St Mary’s Nursing Home is registered to provide personal and nursing care to forty people. The home is situated in the Linthorpe Village, which is close to the town centre of Middlesbrough. Local amenities including shops, a post office, places of worship and banks are within walking distance. St Marys is purpose built. The homes registration was changed in January of 2009. The home is divided into two units. The ground floor of the home can accommodate a maximum number of twenty one older people. The ground floor of the home has two lounge areas and a large dining room. The first floor of the home can accommodate a maximum number of nineteen people with dementia or nineteen people with mental health problems. The first floor of the home has two lounge areas and a dining room. The cost of care at the time of the inspection ranged from £368 to £588 a week. St Marys Nursing Home DS0000000207.V374679.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 two stars – good service. This means that people who use the service experience good quality outcomes. We have reviewed our practice when making requirements to improve national consistency. Some regulations from previous inspections reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the services are not being put at risk or harm. In future if a requirement is repeated it is likely that enforcement action will be taken. This unannounced key inspection took place on 24th March 2009. The manager was present for the morning of the inspection but had to leave at 1PM for a prior appointment. A nurse and care staff assisted with the inspection process on the afternoon. The manager completed and returned an Annual Quality Assurance Assessment, (AQAA). The AQAA is the services self assessment of how they think they are meeting national minimum standards. This information was received before the inspection and was used as part of the inspection process. The reason for the inspection was to see how good a job the home does in meeting the national minimum standards set by the Government for care homes. Numerous records were examined including care records of people living at the home, medication records, risk assessments, complaints and staff records. People living the home and staff working there were also spoken to. Requirements identified at the last inspection in December 2006 were revisited. The details of any issues identified at this inspection requiring action are to be found at the back of this report. What the service does well: St Mary’s Nursing Home provides people that use the service with a good standard of care. Care files for people that use the service contain a map of life; this includes information on school years, family, employment, hobbies, likes, dislikes and St Marys Nursing Home DS0000000207.V374679.R01.S.doc Version 5.2 Page 6 other important and useful information. This information is particularly important when caring for a person with dementia. Assessments and care plans examined contained excellent detail about the person including areas of risk and help needed to promote independence in each activity of daily living. 88 of care staff working at the home have achieved a minimum qualification of NVQ level 2 in Care or equivalent. In general people that use the service are happy with the care that they receive. Comments made included, “I find everyone to be caring and helpful” “They look after me well. Staff are kind and caring” “The girls are good they look after my every need” What has improved since the last inspection? What they could do better: St Marys Nursing Home DS0000000207.V374679.R01.S.doc Version 5.2 Page 7 Staff records of recruitment and training are not up to date as required by regulation for the protection of people that use the service and for the effective and efficient running of the home. The manager has commenced a programme of supervision with staff working at the home; however this is not happening as often as it should be. The manager of the service needs to apply for registration with the Commission for Social Care Inspection. Regular competency checks should be carried out on those people who are responsible for administering medication to ensure that safe practice is being followed. 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 Marys Nursing Home DS0000000207.V374679.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 Marys Nursing Home DS0000000207.V374679.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): Standards assessed 3 People using this service experience good quality outcomes. We have made this judgement using a range of evidence, including a visit to the service. Assessments of people who are to use the service are undertaken to ensure that care needs can be met. EVIDENCE: Before going into St Mary’s people who are to use the service are assessed by a social worker or health care professional. This assessment is forwarded to the home for the manager to look at to determine if the needs of the person can be met. Once this assessment has been reviewed the manager said that she visits the person at home or in hospital to introduce herself, answer any questions about the home and carry out a further assessment on the person. The AQAA states, Comprehensive written information is provided to all prospective clients outlining the ethos of BUPA Care Services and the home as St Marys Nursing Home DS0000000207.V374679.R01.S.doc Version 5.2 Page 10 well as vital information to help with the process of choosing a care home. Prospective residents who are unsure are given the option of a trial in the home to ensure their happiness and wellbeing”. People spoken to during the visit said that they had the opportunity to look around the home before moving in and that they received enough information to make an informed choice. The home does not provide intermediate care. St Marys Nursing Home DS0000000207.V374679.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): Standards assessed 7, 8, 9 and 10 People using this service experience good quality outcomes. We have made this judgement using a range of evidence, including a visit to the service. The health and personal care that people receive is based on their individual needs. Care plans are detailed, which will help to ensure that needs are met. EVIDENCE: The care files of three people that use the service were looked at during the visit. Files examined contained a map of life of the person including school years, family details, employment, hobbies, likes, dislikes and other important and useful information. Assessments and care plans examined contained excellent detail about the person including areas of risk and help needed to promote independence in each activity of daily living. One plan of care detailed how a person liked to sit in the same place in the dining room for their meal, liked small portions of food served on a medium sized place. Another detailed how to respond and reassure a person who could feel insecure. St Marys Nursing Home DS0000000207.V374679.R01.S.doc Version 5.2 Page 12 Care plans and risk assessments are reviewed and evaluated on a regular basis to ensure that they are effective. There is clear evidence of the involvement of doctors, district nurses and other healthcare professionals such as chiropodists. People living at the home confirmed that if they were feeling unwell, the doctor would be called. People spoken to during the visit were in general happy with the care that they received. Comments made included, “The girls are really good they will do anything to help me” “I am well looked after” “Staff are willing, understanding and caring” One person spoken to during the visit did raise some small concerns. The Manager has been informed of concerns raised and is to take action to address. During the inspection arrangements for receiving, storing, administering, recording and disposing of medication on the older persons unit were observed and examined. The manager said that it is the responsibility of senior care staff on the older persons unit to give out medication to any person receiving personal care. For any person receiving nursing care, nurses at the home administer medication. The Manager said that prior to giving out medication care staff do medicine training in safe handling of medication and have their competency checked. Discussion highlighted that competency checks are carried out initially to ensure that staff follow safe practice when dealing with medication, however, not on a regular basis thereafter. Medication practice was good with a clear system for ordering, receipt and returns. The Medication Administration Records were well written with clear direction. Medication was appropriately stored and recorded. St Marys Nursing Home DS0000000207.V374679.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 12, 13, 14 and 15 People using this service experience good quality outcomes. We have made this judgement using a range of evidence, including a visit to the service. People are able to make choices about their lifestyle and contact with family and friends is encouraged. The food provided is appealing and nutritious which is important in maintaining health and wellbeing. EVIDENCE: The home employs and activity co-ordinator who works thirty six hours a week. Activities taking place on daily basis include crafts, games and quizzes. Regular in house entertainment is provided; singers come into the home frequently. The manager advised that activities take place both on the older persons unit and on the dementia unit. She said that both units do come together for activities particularly when there is a big event at the home. The Manager said that people that use the service, relatives and staff had enjoyed Comic Relief Day. Staff and relatives had taken part in a sponsored pogo stick assault course and that fairy cakes had been decorated with red noses. At different times of the year the enclosed garden area for people that St Marys Nursing Home DS0000000207.V374679.R01.S.doc Version 5.2 Page 14 use the service is decorated. At Christmas the area was made into Santa’s grotto, and at Halloween the Chamber of Horrors. At the time of the inspection visit people were busy making preparations for Easter activities. The manager said that one person is a keen supporter of Middlesbrough Football Club and regularly attends home matches with staff. She said that one person attends the local art college. Staff at the home initially took the person and stayed with them until the class had finished, however following risk assessment the person is taken to the college, left and picked up again when the class is finished. This has enabled the person to maintain independence and make new friends. A clothes party had been arranged for the 25th March 2009. Families and friends are made to feel welcome at any time. A discussion took place with the manager regarding equality and diversity. The manager demonstrated through discussion an in depth knowledge. People who want to are supported and encouraged to practice their religion. A representative from a Methodist Church visit every two weeks to do a service. The home has a four week menu plan. The breakfast menu includes cereals, toast, porridge, bacon, eggs and sausages. Whilst walking around the home at 10:30am two people were seen to be enjoying a leisurely breakfast of bacon and eggs. Lunchtime is a lighter meal with the main meal being served at tea time. On the day of the inspection the lunchtime menu of the day was chicken and mushroom soup with a selection of sandwiches. For tea it was corned beef pie or macaroni cheese, both served with potato wedges, swede and cauliflower. Other examples of food served at lunchtime include, salmon fishcakes, jacket potato, or quiche salad. Other examples of food served at tea time include, shepherds pie, lasagne, lamb chops and roast beef. The lunchtime of people on the older persons unit was observed. Lunchtime was relaxed with people enjoying the food that was provided. It was pointed out to the manager that age appropriate background music would be better that the loud pop music that was playing in the dining room area. From 11pm until 6am the home has what is called a Nite Bite menu. The AQAA states, “The Nite Bite menu allows our residents to choose to eat when they feel like it, providing healthy choices at any time through the night. Comments made in respect of the food provided included, “The food is quite good. The portion size is good, I have no complaints” “The food is good. I like the roast dinners” St Marys Nursing Home DS0000000207.V374679.R01.S.doc Version 5.2 Page 15 “There is always a choice if you don’t like something, but most of the time I do like what’s on offer” St Marys Nursing Home DS0000000207.V374679.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): Standards assessed 16 and 18 People using this service experience good quality outcomes. We have made this judgement using a range of evidence, including a visit to the service. People who use the service are confident that their concerns and complaints would be listened to and acted upon. Staff are aware of procedures to follow if abuse is suspected, which helps to protect people who use the service. EVIDENCE: The manager said that since last inspection the homes complaint procedure has been updated as has the statement of purpose to include people rights to complain to the local authority. People spoken to during the inspection said that they could approach the manager or any member of staff to raise any concern that they may have. The home has received seven complaints in the last twelve months. The home has an adult protection procedure which informs staff of who to contact if abuse is suspected. The manager said that staff receive adult protection training when they start working at the home and on a regular basis St Marys Nursing Home DS0000000207.V374679.R01.S.doc Version 5.2 Page 17 thereafter. Records confirmed that staff had last received adult protection training in January 2009. St Marys Nursing Home DS0000000207.V374679.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): Standards assessed 19, 24 and 26 People using this service experience good quality outcomes. We have made this judgement using a range of evidence, including a visit to the service. The standard of the environment is good providing people that live there with an attractive, homely and comfortable place to live. EVIDENCE: St Mary’s Nursing Home is a purpose built, two storey building situated in Linthorpe Village, which is close to the centre of Middlesbrough. The home is close to shops, places of worship, pubs and banks. The home is divided into two units. The ground floor of the home can accommodate a maximum number of twenty one older people. The ground floor of the home has two lounge areas and a small room designated for those people who wish to smoke. There is a large dining room. St Marys Nursing Home DS0000000207.V374679.R01.S.doc Version 5.2 Page 19 Communal areas on the ground floor were pleasantly decorated and homely. At the time of the inspection the corridor areas on the ground floor were in the process of being re-decorated. All bedrooms are single. Bedrooms looked at on the day of the visit were individually decorated according to taste. The first floor of the home can accommodate a maximum number of nineteen people with dementia or nineteen people with mental health problems. The first floor of the home has two lounge areas and a dining room. Lots of thought has been put into the decoration of this unit. One area of the unit is described as a holiday suite and is used to provide respite care. This part of the unit contains four bedrooms and has been decorated in a seaside theme. One corridor area has been developed as a sensory/tactile area for people who use the service to enjoy the experience of touch. This area of the home contains picture frames which have been filled with different materials that have different textures. There are also familiar objects such as bolts fixed to the walls. The manager said that people that use the service particularly enjoy this area of the home. Memory boxes have been placed outside each bedroom and are to be filled with photographs and belongings that will help people to find their bedroom. There is an enclosed garden area for people who use the service. On the day of the inspection the home was clean and tidy. Appropriate laundry facilities were in place. St Marys Nursing Home DS0000000207.V374679.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): Standards assessed 27, 28, 29 and 30 People using this service experience good quality outcomes. We have made this judgement using a range of evidence, including a visit to the service. Staff records of recruitment and training are not up to date as required by regulation for the protection of people that use the service and for the effective and efficient running of the home. Appropriate numbers of staff are on duty which helps to ensure that the needs of people that use the service are met. EVIDENCE: At the time of the inspection there were twenty three people who were using the service, nineteen people on the older persons unit and four people on the dementia and mental health unit. Duty rotas looked at during the visit showed that on the older persons unit there were three care staff on duty from 8am until 8pm, one of which was a senior care assistant. On night duty there are two care staff on duty, one of which is a senior care assistant. On the dementia and mental health unit there were two care staff on duty during the day and night. In addition to care staff on duty there is also a registered nurse. St Marys Nursing Home DS0000000207.V374679.R01.S.doc Version 5.2 Page 21 The manager is supernumerary and works full time. 88 of care staff working at the home have achieved a minimum qualification of NVQ level 2 in care or equivalent. The manager spoke of a robust recruitment procedure that she follows. She said that she makes sure that appropriate references and criminal record bureau checks have been received before new staff start work. It was not possible to evidence this on the day of the inspection. Files for staff appointed from July/August 2008 were disjointed, disorganised and did not contain the required information. One file was that of a staff member who had started work in January 2009 this file contained an appropriate Criminal Record Bureau Check, proof of identity and a job offer letter. References could not be found. Another staff file contained an application form and job offer letter. The manager said that all of the required information was available in the home, however, she has not had an administrator for a while and as such filing had built up. The manager said that both staff had commenced induction training, however records could not be found to confirm that this was the case. Employment records and training records for two staff who had been recruited in 2007 and 2008 were looked at. Files did contain confirmation that a robust recruitment procedure had been followed. Files contained two references, one of which was from the last employer and a Criminal Record Bureau Check. Training records contained evidence of induction and training however had not been updated since July 2008. Staff spoken to during the visit confirmed that they had received mandatory training after July 2008. The manager advised that files would be brought up to date when an administrator was appointed. St Marys Nursing Home DS0000000207.V374679.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): Standards assessed 31,33, 35 37and 38 People using this service experience good quality outcomes. We have made this judgement using a range of evidence, including a visit to the service. Quality assurance monitoring systems are in place to ensure that the home is run in the best interest of people that use the service. Supervision of staff does not happen as often as it should do to ensure that staff are competent in all aspects of their work and receive appropriate training EVIDENCE: Since last inspection of the service a new manager has been appointed. The manager is a Registered Mental Nurse who has many years of experience St Marys Nursing Home DS0000000207.V374679.R01.S.doc Version 5.2 Page 23 working with people with dementia and people who have mental health problems. She said that that she has just completed a management qualification and is to forward her application to register as manager to the Commission for Social Care Inspection. The manager advised that quality assurance monitoring systems are in place. Surveys are sent out to people that use the service on a yearly basis to make sure that they are happy with the home and the care that they receive. Regular meetings are held for people who use the service and their relatives. The home looks after small amounts of money belonging to some people who use the service. Appropriate records of transactions are kept. Although individual records are kept of money being held for each person, money is pooled into one account. The manager said that interest earned on the account is shared out according to the persons balance. Money should be kept/banked individually. Records were examined to confirm that the manager has commenced a plan of supervision with staff working at the home; however staff are not receiving supervision as often as they should. As highlighted previously Staff records of recruitment and training are not up to date as required by regulation for the protection of people that use the service and for the effective and efficient running of the home. The manager advised that maintaining and updating records has been difficult with not having an administrator. A sample of health and safety records were examined and found to be in order. Records were available to confirm that the homes fire extinguishers and gas boilers had been serviced in the last twelve months. On average weekly tests of the homes fire alarm system is carried out to ensure that it is in working order. Cleveland Fire Brigade visited the home in March 2009 to carry out a fire safety audit the outcome of which was considered to be satisfactory. The manager said since last inspection all window restrictors on the first floor of the home have been replaced and that they are checked on a regular basis to help to ensure the safety of people that use the service. St Marys Nursing Home DS0000000207.V374679.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 2 3 St Marys Nursing Home DS0000000207.V374679.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 OP29 OP37 Regulation 19 Requirement Timescale for action 30/06/09 2 OP30 OP37 17 The registered person must ensure that information and documents as detailed in Schedule 2 of the Care Homes Regulations 2001are kept on the files of people employed at the home. This will confirm that that a thorough recruitment procedure has been followed and safeguard people that use the service. The registered person should 30/07/09 ensure that staff training files are brought up to date to confirm that induction, mandatory and other relevant training has been provided to staff. 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 St Marys Nursing Home DS0000000207.V374679.R01.S.doc Version 5.2 Page 26 1 2 OP9 OP31 3 4 OP35 OP36 Regular competency checks should be carried out on those people who are responsible for administering medication to ensure that safe practice is being followed The Manager should forward her application for registration as manager to the Commission for Social Care Inspection. This will enable the Commission for Social Care Inspection to assess fitness and register The registered person should ensure that money belonging to people that use the service is kept individually The manager should ensure that all staff receive supervision on a regular basis to help to ensure that staff are competent in all aspects of their work and receive appropriate training St Marys Nursing Home DS0000000207.V374679.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region Citygate Gallowgate Tyne and Wear NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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