Care Home: St Michael`s

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What the care home does well The home is well-run and provides a comfortable and homely place for the people who live there. The staff are a competent team who were observed to be kind and polite when speaking with residents or their visitors. The manager and staff provide daily activities which are tailored to the needs, wishes and age of the residents. The manager holds regular residents’ and relatives’ meetings, gives out survey questionnaires every six months and publishes the findings of the information gathered. The manager and staff are meeting the National Minimum Standards. What has improved since the last inspection? Although this home was being inspected for the first time as a new service, the home was already established and in its last inspection report, there were four requirements. These included one for the safe administration of medications; one for better activity provision; one for the owner or responsible individual person to visit the home monthly, unannounced and one was for improving the regularity of the one-to-one meetings with staff by the manager or a senior staff member. There was also a recommendation that the staff training plan needed to be produced and kept up-to-date. The current manager has taken action to address all the requirements and the recommendation raised at the last inspection. Improvements to the decorations and furniture have continued both inside and outside the home and at the time of the visit to the home, were nearing completion. What the care home could do better: Two requirements were made at this inspection. The service user guide and statement of purpose must contain sufficient details for people to have all the facts necessary for them to decide if the home will be suitable for their needs and wishes, including where to go to make any concerns and complaints known and how they will be responded to. A requirement was made to improve the quality of and increase the information in the statement of purpose and service user guide. New staff must not be employed to work without being fully supervised until all the legal checks have been completed and records returned to the manager.St Michael`sDS0000073192.V375825.R01.S.doc Version 5.2 However, the manager told us she is keen to continue to implement any improvements as they become evident through the communication methods in place for people, relatives and staff to have their say. Key inspection report CARE HOMES FOR OLDER PEOPLE St Michael`s High Street Waddington Lincolnshire LN5 9RF Lead Inspector Vanessa Gent Key Unannounced Inspection 10th June 2009 10:30 DS0000073192.V375825.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 Michael`s DS0000073192.V375825.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 Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Michael`s Address High Street Waddington Lincolnshire LN5 9RF 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) 01522 723292 stmichaels90@btconnect.com Prime Life Ltd Ms Kay Rushworth Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places St Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories 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 - Code OP The maximum number of service users who can be accommodated is 40 This is the first key inspection as a new service 2. Date of last inspection Brief Description of the Service: St Michael’s is a purpose-built, privately-owned, single-storey care home providing personal care, both long-term and for respite, for up to forty people of either sex over 65 years of age, some of whom may have dementia. Within the past six months it has been purchased by the Prime Life company. It is situated in the village of Waddington, which has an RAF base close by and is eight miles from the city of Lincoln. The home is on the high street and there is a bus stop directly outside. In the village, there is a pharmacy, general stores and a newsagent’s. The parish church is close by and there are three pubs, one of them next door. All the village amenities are within walking distance of the home. The home has monthly access to a wheelchair-accessible minibus shared with other homes in the company, for trips out and people’s health appointments. The accommodation consists of forty single bedrooms, all ensuite with toilet and washbasin; four of these also have a shower. Communally there are two lounges, a conservatory, two dining rooms, three bathrooms, one with a specialist bath for people with restricted mobility and two with a toilet, two shower-rooms, one with a toilet, and one separate toilet, used mostly by staff and visitors. Within the area of the main dining room, a resident’s kitchenette has been set up where people or their visitors may make light refreshments and drinks. Next to this is a tall, cooler cabinet which is kept topped up snacks, cold drinks and fruit for people to help themselves to at any time. St Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 5 The central garden is accessed from either the conservatory or the patio doors in the dining room. It provides a beautifully maintained, secure, tranquil outdoor area for residents to sit in. At the front of the home, there is enough parking for approximately ten vehicles. The fees ranged from £420 to £450, depending on the level of need of the residents. Additional charges were made for services such as chiropody, hairdressing, personal newspapers and toiletries. Information about these costs as well as the day-to-day operation of the home should be found in the home’s statement of purpose and service user guide. These documents and a copy of the last inspection report are available to all living or interested in the home to explain the resources and services offered by the care home. An intermediate care service is not available at the home. St Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This is a summary of what the inspector found during the visit. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The people living in the home wish and are happy to be called ‘residents’, and the manager, staff and visitors agree with this, as will be reflected in this report where applicable. An unannounced visit was made to the home as part of a key inspection. It started at 10.30 and lasted 5½ hours. The manager had completed a questionnaire called the Annual Quality Assurance Assessment (AQAA) giving important information about the service and this was used to contribute to the inspection process. Information from this, as well as that which we hold about the service, was used to plan the visit and produce this report. The main method of inspection used is called ‘case-tracking’, which involves selecting a proportion of residents, and tracking the care they receive through the checking of records, discussion with them, the care staff and observation of care practices. The site visit focused on whether key standards and requirements from previous inspections had been met and how the people feel about the service provided. We looked at the care given to three people to ensure their health, safety and welfare is checked and that they are given dignity, autonomy and choice. The three residents we case-tracked, several visitors and three staff on duty spoke with us. People spoke about their experience of living at the home. Their personal records, general house records and staff records were looked at and the way care was given to the residents was observed. We also spoke with people in their own rooms and some sitting in various communal areas of the home. Any comments we received will be mentioned in the main body of this report. We made a partial tour of the home. The manager was present throughout this inspection. St Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 7 What the service does well: The home is well-run and provides a comfortable and homely place for the people who live there. The staff are a competent team who were observed to be kind and polite when speaking with residents or their visitors. The manager and staff provide daily activities which are tailored to the needs, wishes and age of the residents. The manager holds regular residents’ and relatives’ meetings, gives out survey questionnaires every six months and publishes the findings of the information gathered. The manager and staff are meeting the National Minimum Standards. What has improved since the last inspection? What they could do better: Two requirements were made at this inspection. The service user guide and statement of purpose must contain sufficient details for people to have all the facts necessary for them to decide if the home will be suitable for their needs and wishes, including where to go to make any concerns and complaints known and how they will be responded to. A requirement was made to improve the quality of and increase the information in the statement of purpose and service user guide. New staff must not be employed to work without being fully supervised until all the legal checks have been completed and records returned to the manager. St Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 8 However, the manager told us she is keen to continue to implement any improvements as they become evident through the communication methods in place for people, relatives and staff to have their say. 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 Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 9 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 Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 10 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, 6 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. Information about the service is available to help people decide whether the home will be suitable and meet their needs. The manager carries out a full assessment of all prospective new residents to make sure that they can meet the needs of people who want to live there. EVIDENCE: We were told that the statement of purpose was part of a ‘standard brochure pack’, given to anyone interested in coming to live in the home and to those who already live there, to show how the service is run. We saw this pack which contained a one-page information sheet headed, “An Introduction to St Michael’s” where it states “St Michael’s has a specific statement of purpose, St Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 11 detailing the important ethos of the care culture”. This was not included in the brochure pack. The brochure pack included a glossy brochure, entitled “An Introduction to Bespoke Services to Elderly Client” which was written in clear, large print with associated pictures and brief descriptions. We saw that this brochure included statements such as people are “encouraged to share with us those aspects of the service with which you are satisfied, and those that you wish us to review.” They also state, “there are a number of ways to convey your views.” “It is always our intention to . . . address any issues of concern.” All the residents we spoke with had lived at the home since before the new owners had taken over. A relative told us that they had been given enough information to help them decide if the home was suitable for their relative to live in. We were told in the manager’s annual quality assurance assessment, “We provide assistance to those clients that require same, the information is available in different languages, in a simplified pictorial format or if necessary brail.” We did not review any different formats at the visit and no-one we spoke with was aware of other ways to receive the information about the home and service provided. We were told that people who were interested in coming to live at the home were visited by the manager or a senior staff member in their previous home situation to assess whether they could meet the needs of that person. People confirmed that this happened for them. We also saw signatures of the person or their representative on the initial assessments in the care plans of the people whose care we checked particularly. The manager does not offer intermediate care at the home. St Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 12 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 are cared for safely and in a dignified manner, and their needs met by clear care plan documents, good liaison with other professionals and safe medication practices. EVIDENCE: The care plans we saw of the people whose care we monitored were comprehensive documents which described in detail the care the staff needed to give the residents, with risk assessments for each of their needs, and how they should be managed. We looked at the care plans of three people. They all contained risk assessments, and told how the resident’s health and personal needs were to be met. Care staff said they know from the care plans how to provide the St Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 13 appropriate care and support for the residents. People told us they are happy with the care given by the manager and staff. A relative said, they are very good at caring. The manager told us in her self assessment that “people are involved in decisions with regard to their personal care”, and other aspects of their lives. The care plans we checked did not incorporate the relevant section of the Mental Capacity Act 2005 in relation to the ability of people to make judgments about the care they wish to receive. The manager told us that staff are due to have training in how to put into action the principles of the act; staff confirmed they had not yet had this training. The care plans showed that the staff review peoples care plans regularly, to assess and monitor their changing health needs. We were told the resident is involved where and when they want to be. One persons care plans showed us they were involved with reviewing their care plans as they want. People told us that staff call a doctor if they become poorly. One persons care plans showed that the doctor was called regularly when they were very poorly. A relative told us they come to visit regularly but the staff keep them fully informed of any changes that occur. They cited a particular incident where they had been contacted immediately. They told us that someone from the home went with the person to the accident and emergency department at hospital and there was very good communication from staff. All of the people living in the home wanted or needed help with their medications. The manager told us that a lockable facility is provided in each bedroom, for personal items and if any resident wants and is able to ‘see to their own medicines’. The manager told us and records showed that the supplying pharmacist audits the medication practices regularly and reports back to the manager. Staff stated that they have had good training in how to give medicines safely. We saw evidence to confirm this. People said they were treated with respect. We saw the staff behaving in a considerate, gentle, friendly way with people when giving support, especially to people who were very poorly. One person said, Theyre very kind, helpful and pleasant. Visitors told us, “They’re caring and very good, very loving and kind. [The resident] is in good hands.” St Michael`s DS0000073192.V375825.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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. All aspects of the people’s lives are catered for by a variety of activities, encouraged contact with the community, family and friends, autonomy and choice and a balanced diet. EVIDENCE: People told us there is a variety and good quantity of activities. A person said, “There’s activities most days. I like to join in but they never make you if you don’t want to. They take us on outings. I’ve been to Mablethorpe and a garden centre.” Another person said, “I like it quiet really but they ask us what we enjoy so I sometimes join in as I fancy. We have a regular coffee morning every week and some of these are for the residents’ meetings and our relatives are invited too. The manager runs these. We have our say and they put on what we want.” St Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 15 Visitors told us they always feel very welcome. They said it is nice to be able to go into the kitchenette and make refreshments with their relative. They told us there have been “great improvements since the new owners came in. I could come to live here myself, it’s so good now.” People said they have full choice in their lives, including what time they get up, what to wear, what to eat and where to sit in the daytime, with plenty of choice of places to be comfortable in. We asked what the food was like and several people said, “There’s plenty of choice.” “The food is fantastic.” However, one person felt the menu was not very imaginative and wished there was more fish on the menu rather than just on Fridays. They also said they would sometimes like the choice of a cooked breakfast on more days. They felt it should be discussed at a residents’ meeting. A visitor said that her relative had been undernourished when they came to live in the home and often said they were hungry before the new owners took over. Now, however, they said, the person never moans about feeling hungry, especially with the unlimited access to the food cabinet in between meals and drinks being served often. St Michael`s DS0000073192.V375825.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, 18 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. Complaints are taken seriously and investigated in an appropriate manner. Staff are well-trained to keep people safe at all times and people feel safe and comfortable in the home. EVIDENCE: The complaints policy was not in the statement of purpose or service user guide that we were given. People told us they knew who to go to if they were not happy with any aspect of the service provided but no-one we spoke with had felt the need to use it since the last inspection. People told us they were “more than happy with the care. The staff are very diplomatic and lovely. They’re beautiful girls. I’m very happy to be living here.” Visitors said, “When we’ve mentioned anything, there’s been no hesitation about putting things right. If I said anything to the manager, I know she’d deal with it discreetly and straight away.” St Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 17 Staff told us they have had training in how to protect people. Their training records confirmed this. They said that if they saw any poor practice by one of their colleagues, they would not hesitate to inform the manager. Since the new owners have taken over, the manager has told us how she has taken action to protect people from abuse. The manager has made two referrals to us and the county safeguarding team regarding staff issues and safeguarding adults. We have seen that both have been dealt with appropriately and within a reasonable timescale. The information we received showed the manager had acted appropriately and communicated with other professionals in order to make sure people were kept safe from harm. St Michael`s DS0000073192.V375825.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, 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. The home provides a comfortable, clean, attractive environment to ensure the residents are cared for safely and feel ‘at home’. EVIDENCE: The chairman and owner of the company wrote, Yet another rescue project, the building has been totally refurbished, we have created some exciting new initiatives including the Lancaster Café, enhancing the internal gardens, and improving the single room en-suite facilities which quite frankly previously were woefully deficient. We have created new office and staff room facilities, we have refurbished all of the day rooms, the bathrooms and WCs.” St Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 19 The refurbishment programme has been completed and the manager and provider are awaiting visits from the fire safety, environmental health and other building inspectors, to give their verdict and approval on the safety and competency of the home to provide a safe and comfortable environment for the people who live there. We saw that the building was light and airy, clean and tidy. Visitors told us, “It is a vast improvement to what was there before. Now it’s so open and bright. It is cleaner and fresher.” People and visitors said they really like the new café which, staff told us, will provide flexible eating times for people to come to as and when they were ready to eat, although this latter facility was not up-and-running at the time of the inspection visit. The dining area has been split up into smaller, more intimate sections, to give the appearance of a restaurant and to give people more privacy and dignity whilst eating. In the corner of the dining area, a refrigerated chill-cabinet has been installed, from which people can help themselves to snack food, fresh fruit and drinks at any time of day. There is also a kitchenette where residents or visitors can make drinks and light refreshments for themselves or with assistance from staff. People said they were very happy with the new décor, that their rooms were cosy, clean and comfortable and that having their own toilet gave them more privacy and dignity. The central, secure garden area was attractively landscaped and maintained, and provided people with a tranquil, safe place to sit out in. People said, “It’s really beautiful out there now. It’s lovely to sit in when the weather’s good.” The manager said they were planning some raised-level gardening facilities to enable people to do some gardening, without having to stoop or bend down too much, and for them to grow food, plants and flowers themselves, should they wish. Staff told us that the hygiene, pleasant appearance and safety of the home was well-maintained. Chemicals were locked away; the maintenance man visited weekly or more often if required. Two staff were on cleaning duties daily. People told us their rooms and the communal areas are always kept spotlessly clean. The laundry is done in commercial washing machines, one of which has a sluicing facility. A person said, “The laundry’s ever so good.” The fire safety officer reported, on 03/09/07, that all doors were not to be propped open and a previous requirement had been made to stop this practice. This had been addressed and all doors to be kept open now have door-guards fitted. The Environmental Health Officer last visited on 04/03/09 and had no problems to report. St Michael`s DS0000073192.V375825.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 are cared for by staff who are skilled and well trained enough to meet their needs and wishes at all times but who may not be safely recruited. EVIDENCE: Visitors told us, “The staff are all nice to her. They don’t seem rushed. They always have time to chat to us. They consider people’s wishes. Nothing’s too much trouble for them.” People said that there are usually enough staff on duty although in the evenings and during the night, they were “a bit shortstaffed sometimes.” A visitor told us that when their relative rang for a staff member, someone came straight away. During our visit, the bells people used to summon attention were answered promptly. The staff duty rota showed that there are enough staff on duty for most of the days for the number of residents and their dependency needs, and taking into consideration the sprawling layout of the building. However, there are normally less staff on duty in some of the afternoons and evenings and the staffing numbers at these times and at night need re-assessing to ensure the people are safe and well-cared for at all times. St Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 21 Newly-employed staff told us they were happy with the induction process, which had lasted for up to twelve weeks; that they had shadowed staff until they felt competent and ready to care for people on their own. People told us, however, that some staff had started working before the legal checks needed were completed. A Protection of Vulnerable Adults (POVA) first check had been completed but we were advised that some new staff were not always supervised in their work at all times. People told us they always felt safe with the staff, who were lovely, helpful, friendly and kind.” We saw the training records which showed people were being trained by the new owners. Some staff told us that although they were fully trained by the previous owners, Prime Life like them to all be trained to their standards and they have had lots of training in the past six months, with more “lined up for the near future”, such as training for how to protect people and the Mental Capacity Act 2005. Staff said they felt able to deliver a good quality of care to the residents. St Michael`s DS0000073192.V375825.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, 32, 33, 35, 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. The home is run for the benefit, safety and in the best interest of the people who live there and the staff. The residents feel safe and enjoy living at the home. EVIDENCE: The manager has been in post since before the purchase of the home by the new owners. She is registered with us and has achieved her Registered Manager’s Award. St Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 23 Visitors told us, “The manager’s very nice. Things are settling down now. She thawed very quickly and became very friendly. She is very good at informing us of anything. We know [the resident] is in good hands.” A resident told us, “I see the manager round although she doesn’t come to visit me in my room.” People told us that there are weekly coffee mornings and once a month they use it as the residents’ and relatives’ meetings, which they are encouraged but not forced to attend. We were told that they can discuss anything at the meetings and the manager will take ‘on board’ any request for change. Staff told us they feel very supported by the manager and the company. “There’s plenty of support. The manager and people from Prime Life are approachable. They wanted to know if any extra support was needed. They visit often.” Staff also said they could have their say and felt that the owners listen to them, discuss things with them and put things into action where it will improve the lives of the residents, for those who have association with the home or themselves as staff members. The manager told us she has been establishing audits on various aspects of the service, such as medications, care plans and the kitchen. She showed us evidence that this was so. She said she gives out surveys to residents, visitors and healthcare professionals, to gain people’s views and monitor how well the service is doing. The information from surveys is then collected and sent to head office for analysis to help to improve the service. One resident told us, “I think it’s better; in fact, it couldn’t be better than it is now. There’s a nice atmosphere; the staff are friendly – they make you feel at home; the food’s good; the garden’s beautiful. There’s nothing I don’t like now.” The records we saw and the statements in the manager’s self assessment showed us that the home is well-maintained and health, safety and hygiene measures are in place to ensure people are cared for in an appropriate manner. People told us that the improvements made to the environment has made it more comfortable and pleasant for them. St Michael`s DS0000073192.V375825.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 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 No St Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 25 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 Standard OP29 Regulation 19(1)(b) Requirement New staff must not start in their work at the home until all the legal checks have been completed and satisfactory records returned to the manager. This is to ensure that residents are protected. Timescale for action 01/09/09 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 Michael`s DS0000073192.V375825.R01.S.doc Version 5.2 Page 26 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA 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. 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