Inspection on 15/02/07 for Caritate Nursing Home

This inspection was carried out on 15th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Caritate Nursing Home 10/02/09

Caritate Nursing Home 18/10/07

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Caritate Nursing Home Laninval House Treningle Hill Bodmin Cornwall PL30 5JU Lead Inspector Paul Freeman Unannounced Inspection 15th February 2007 10:00 Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Caritate Nursing Home Address Laninval House Treningle Hill Bodmin Cornwall PL30 5JU 01208 75628 01208 74921 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) Caritate Limited Care Home 27 Category(ies) of Physical disability (27) registration, with number of places Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 15 service users may be over 65 years of age who require nursing care and accommodation by reason of old age or physical disability. Three named service users may be accommodated who require care and accommodation by reason of old age, not falling into any other category. Date of last inspection Brief Description of the Service: Caritate was previously known as Laninval House and is situated approximately two miles from the centre of Bodmin in its own grounds. It is an older, privately owned property with an added extension. It offers nursing care to younger people with disabilities and is viewed as a home for life if this is the wish of the person concerned. A number of residents are dependent on a wheelchair for mobility. The ground floor of the home provides mainly communal space and is divided into several separate and distinct areas. There are also two sun where smoking is permitted. Bedroom accommodation predominantly comprises of single rooms and the providers are currently considering with residents the best use of the space available. Stairs and a shaft lift provide access to all the floors and a range of disability equipment is avaliable to assist residents. Externally there are large grounds, much of which is level and accessible by wheelchair. A car park has also recently been established at the front of the building. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The registered providers have changed since the last inspection dated 23 January 2006. Therefore the key inspection that took place on 15 February 2007 was the first inspection in regard to the new providers. Two inspectors completed the inspection and the purpose of this inspection was to consider the core standards. Therefore some of the key standards considered included care planning, health, staffing arrangements and safe working practices. Consultations took place with the registered provider, staff, residents and visitors to the home. Records and documents were also considered. The Inspectors noted the new providers had made dramatic steps to improve both the service and facilities provided. Prior to the current registration the Commission were concerned about the environmental standards and the limitations of the documents and records held at the care home. It is clearly evident the new providers have positive and ambitious plans to improve and develop the facilities and services. However the initial focus has been upon improving the day-to-day lives of residents and their surroundings. To this end the providers have made positive steps and residents were very complimentary about the improvements and the manner in which the home is managed. What the service does well: The providers complete a needs assessment for each prospective resident to make sure they can provide the care and support required. The prospective resident is invited to participate in the assessment and the views of their relative, representatives or any key professionals are also taken into account. Residents said they were able to make their own decisions about every day living and were given support and assistance when required. The residents are also very positive about the care and support provided. Many residents said they were able to direct their own care and the staff positively responded to any requests they made. Good arrangements are in place to promote residents health and there are no barriers to residents accessing health services when required. Generally prescribed medicines are also managed safely. Suitable arrangements are in place to protect residents from abuse and to deal with residents’ complaints or concerns. This promotes the residents safety and makes sure that any concerns are dealt with positively. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 6 Good arrangements are in place to offer a clean and hygienic setting. Good training arrangements are in place and sufficient numbers of staff are on duty each day and night. The home is well managed and the providers have wide ranging experience of providing and delivering residential services and facilities. What has improved since the last inspection? The new providers have significantly improved and developed the care planning arrangements. This makes sure that staff are given clear guidance and direction about the needs of each individual resident, their preferences and choices. Good arrangements have been put in place to regularly review and update the plans. The new providers are in the process of reviewing, developing and improving the risk assessment and risk management arrangements. This will make sure that every reasonable step is taken to safeguard residents. The providers have improved the choice and quality of the food provided to make sure a nutritionally balanced diet is in place that reflects the needs and preferences of residents. Residents said they were very pleased with the changes. The dining room has also been refurbished to a high standard and now offers residents a quality setting. The providers have also been instrumental in improving and developing the social and recreational opportunities. This continues to be an ongoing feature and is taking place in consultation with residents. Historically the environment has been poorly maintained but the new providers have taken positive steps to address the shortfalls to improve and develop the facilities provided. The work completed to date has included the creation of a new bathroom ands toilet with a Parker medibath. A new laundry is also being established and a new food store has been developed in the main house. The providers are determined to offer accommodation that exceeds the minimum standards and the standard of the work completed to date is very good. The providers have significantly improved the staff records and recruitment arrangements to make sure that residents are safeguarded. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 7 There is evidence that residents are regularly consulted but formal quality assurance measures are not yet in place, although planned. These will further improve and develop the consultation arrangements. Positive efforts are being made to improve and develop safe working practices to make sure that every reasonable step is taken to safeguard residents. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standard considered was 2 Quality in this outcome area is good. Good arrangements are in place to assess prospective residents needs that also make sure the providers are able to meet the care and support needs of the person concerned. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The providers have established arrangements that make sure all prospective residents are assessed in order they can have a clear picture of their needs. The prospective residents are invited to participate in the process and the views of their relatives or representatives are also taken into account. Furthermore the providers consult with any key professional that are involved with the person concerned. This makes sure the providers have a clear picture of the individual’s needs and are confident they are able to provide the care and support required. Residents that had recently moved to the care home confirmed they were fully involved with the assessment arrangements. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 10 The residents said they had been positively welcomed by the managers, staff and residents and were very positive about the care and support provided. In addition the residents stated they had been able to visit the care home before their move to make sure they were satisfied it was a suitable setting that is able Residents commented the visiting arrangements were flexible and they had been able to deicide the most appropriate visiting arrangements to help them make an informed decision about the move. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 6, 7 and 9. Quality in this outcome area is adequate. Significant improvements have been made with the care planning arrangements so that the most appropriate and up to date care and support can be provided. The arrangements to assess and manage risk also continue to improve in order that residents are safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The providers have established new care planning arrangements and are in the process of applying the new arrangements to every resident. Once completed the plans will provide staff with good information, direction and guidance about the care and support required. Residents are encouraged to fully participate in their care planning and many residents said they are able to direct the care Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 12 and support they require. Where residents are not able to direct their care it is advised that more detailed plans are in place. The care planning arrangements are significantly improved given previously residents were reliant upon the staff knowledge and skills to meet their needs as the records available about their care needs were very limited. The providers are also establishing arrangements that make sure the plans are regularly reviewed with each resident. The regular reviews will also ensure the plans accommodate any changing needs, preferences or choices. It is evident that residents are encouraged and supported to make their own decisions whenever this is possible. There are also no barriers to residents accessing advocates where required. The providers have also begun to improve and develop the risk assessment and risk management arrangements. The registered provider said that a suitably experienced nurse was actively taking a lead role in developing the arrangements. Historically risks appear to have been managed on the basis of the individual staff members’ knowledge and skills. The current providers are taking a more measured approach that includes improved policies and procedures, ensuring that staff are suitably trained and reliable and robust arrangements to identify unreasonable risks and put good measures in place that safeguard residents and staff. The Inspectors commented on the importance of good records in regard to assessments and management plans so that staff are provided with clear guidance and directions. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. The providers continue to make positive steps so that residents can experience a stimulating and varied lifestyle. Residents are provided with a flexible daily routines are able to direct their own care. A varied and nutritional menu is in place that reflects the resident’s preferences, choices and needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents said that historically there had been limited opportunities to participate in activities at the home or in the local community. Residents were Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 14 pleased the new providers were making positive steps to improve and develop the range of options available. It is evident that activities were taking place on the day of the inspection and it was also clear that staff have the opportunity to spend some social time with residents. In addition the providers have purchased a minibus and this has significantly improved the opportunities for residents to regularly access the community. Residents, relatives and staff are working together to establish plans to further broaden opportunities. All stated that the providers positively receive any ideas. It is clear the providers are committed to offering residents a varied and stimulating lifestyle that reflects their interests and hobbies. The daily routines at the home are flexible and reflect the residents’ preferences and choices. Residents said that staff were responsive to their requests and stated they felt in control of their lives and the care and support provided. The providers have also reviewed and revised the menu in consultation with residents. Residents were very positive about the current menu, which they considered reflected there needs, preferences and choices. The providers have taken steps to make sure the menu is nutritionally balanced and that residents are given a choice of the food they have at each mealtime. The kitchen staff is also able to cater for special diets. Plans are being finalised to refurbish and up date the kitchen given the current facilities and some of the kitchen equipment requires improvement. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 18, 19 and 20. Quality in this outcome area is good. Good arrangements are in place to promote residents health and there are no barriers to residents accessing health services when required. Generally prescribed medicines are managed safely but the records regarding the administration by suitably qualified staff require improvement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents and visitors were very confidant about the arrangements to meet health care needs. It is also clear that health services are promptly accessed when required. The residents also had confidence in the staff and the support they provide at times of poor health. The residents are able to administer their own prescribed medicines when safe to do so. Where assistance is required the trained nursing staff provide this. Generally the arrangements are sound and medicines are stored safely. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 16 However the records keeping arrangements require improvement to make sure a suitably comprehensive record is in place. The providers are actively making sure that comprehensive policies and procedures are in place and that medicines that are no longer required are safely disposed. Good arrangements are in place to store and manage any prescribed controlled drugs. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 22 and 23. Quality in this outcome area is good. Suitable arrangements are in place to protect residents from abuse and to deal with residents’ complaints or concerns. This promotes the residents safety and makes sure that any concerns are dealt with positively. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The providers or the Commission following the provider’s registration has received no complaints. The home has a satisfactory policy and procedure for dealing with complaints and residents commented there are no barriers to raising concerns or issues with the providers or staff. It is also evident that relatives or representatives are made aware of the complaints procedure and the providers said that visitors are encouraged to raise any concerns or issues. The policy and procedure regarding adult protection is satisfactory and meets with the National Minimum Standards. In order to protect residents any concerns are reported to the statutory agencies and where necessary a formal investigation is undertaken. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 18 Satisfactory whistle blowing arrangements are in place for staff. This enables staff to report any concerns to a third party if they feel unable to tell the providers. This provides further protection for the residents. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 24 and 30. Quality in this outcome area is adequate. Historically the environment has been poorly maintained but the new providers have taken positive steps to address the shortfalls and to improve and develop the facilities provided. The providers are determined to offer accommodation that exceeds the minimum standards and the standard of the work completed to date is very good. Good arrangements are also in place to provide a clean and hygienic setting. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The last inspection report stated, “Floor coverings in the hall, stairs and first floor are worn and stained and look drab. There is a very tight right-angled turn through two doorways on the first floor. It is evident from the markings on the walls and damage done to the fabric of specialised chairs that this is too narrow or that staff need to take greater care when trying to manoeuvre Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 20 through. There was similar evidence of narrow doorways where chairs and equipment have torn lagging on hot water pipes. There has been no progress in updating the bathing and toilet facilities and in fact one bathroom continues to be out of use and has been so for at least a year. The registered provider said that they were unlikely to initiate any changes in the bathrooms and toilets as they wished to retire and would leave any major alterations to a new owner. They felt the shower trolley that could be used by a person’s bedside was a satisfactory solution.” In addition the current providers have identified a number of issues in regard to the fabric of the building that needed urgent attention. These included making the building watertight, mains water repairs, better laundry facilities and equipment and suitable car parking facilities. In a relatively short period of time the providers have made significant improvements to improve the facilities, make sure they are watertight and begin to develop quality accommodation for residents. This can be illustrated by the recently refurbished dining room, which the residents are very positive about. The dining room has been refurbished to a high standard and offers residents a good dining experience that is equitable with a quality hotel. In addition the newly constructed bathroom shows a very high standard. The providers have established a refurbishment plan for the building, which if based upon the current standard of work will result in the facilities exceeding the minimum standards. In addition the providers have commenced an extensive redecoration and furniture replacement programme. The residents’ and visitors are very satisfied with all the recent improvements and value the work that has been completed to date. In addition the providers regularly informally consult residents about the environment to make sure that every step is taken to provide the best facilities possible. The home is clean and hygienic and residents are very satisfied with the standards maintained by the present providers. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 32, 34 and 35. Quality in this outcome area is adequate. The providers have significantly improved the staff records and recruitment arrangements to make sure that residents are safeguarded. However the vetting arrangements require further development in order that newly appointed staff are robustly vetted. This will provide further safeguards for residents. Good training arrangements are I place and sufficient numbers of staff are on duty each day and night. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff at the home have historically been a positive feature of the service provided and the last inspection report said “ The staff team appeared to be helpful towards service users and were aware of each person’s needs and preferences in the way they were approached.” Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 22 Sufficient numbers of staff are on duty each day and night and additional staff are employed if required by the residents needs. In addition the registered providers play an active role in the day-to-day delivery of services. Staff are clear about their roles and responsibilities and stated that good training arrangements are in place. It is also clear that staff feel they are well supported and are able to access advice, guidance and direction when required. The staff team stated they work well as a team and are mutually supportive. The providers have improved and developed the recruitment, selection and vetting arrangements to make sure that every reasonable step is taken to safeguard residents. The providers must be mindful that newly appointed staff must have a POVA check before they can commence their duties. There were occasions recently when this had not taken place. Potentially this could compromise residents’ safety. However the providers have taken steps to make sure the required records are in place for established staff. At the time the providers took over they found the staff records to be poor. This has made sure the records required by regulation are in place for established staff. Staff that had recently begun to work at the care home said they were positively welcomed and had completed a good induction programme. The providers stated they were working to the recently established Skills for Care induction guidance. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 37, 39 and 42. Quality in this outcome area is good. The home is well managed and the providers have wide ranging experience of providing and delivering residential services and facilities. There is evidence that residents are regularly consulted but formal quality assurance measures are not yet in place. These will further improve and develop the consultation arrangements. Positive efforts are being made to improve and develop safe working practices to make sure that every reasonable step is taken to safeguard residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 24 The new providers have brought wide experience of the provision and management of care homes and therefore have a wide range of social care, nursing and business skills. The staff, residents and visitors consider the services and facilities are now well run and reliably managed. They also stated the providers were responsive, attentive and proactive in regard to any issues, concerns or suggestion they had. At the time of the inspection the providers had not established formalized arrangements to undertake quality assurance measures in order they can effectively consult with staff, residents and stakeholders. It is clear that certain arrangements are in the process of being established. It is also evident that it is the providers’ intention to establish reliable arrangements in the year ahead. The new providers have put in place a range of measures to promote safe working practices. These have includes establishing robust policies and procedures and making sure that staff have up to date knowledge and skills through a range of training opportunities. As the report details earlier risk assessment and risk management arrangements are actively under consideration. This should make sure that reliable safeguarding arrangements are in place for residents and staff. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/a 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 YA6 Regulation 15(1) 15 Requirement Service user’s plan Timescale for action 30/09/07 (1) Unless it is impracticable to carry out such consultation, the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan (“the service user’s plan”) as to how the service user’s needs in respect of his health and welfare are to be met. Each resident must have a suitably detailed and up to date plan of care. 13(4)(a-c) (4) The registered person shall ensure that— (a) all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; (b) any activities in which service users participate are so far Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 27 2. YA9 30/04/07 as reasonably practicable free from avoidable risks; and (c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated, Good risk assessments and risk management plan must be in place for any situation that could potentially compromise the health, safety or well being of a service user. (2) The registered person shall 30/04/07 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Where a staff member assists a service user to administer their prescribed medication accurate, complete and up to date records must be maintained. 23 Fitness of premises (1) Subject to regulation 4(3), the registered person shall not use premises for the purposes of a care home unless— (a) the premises are suitable for the purpose of achieving the aims and objectives set out in the statement of purpose; and (b) the location of the premises is appropriate to the Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 28 3. YA20 13(2) 4. YA24 23(1) (a-b) (2) (a-b) (j-l) 30/01/08 needs of service users. (2) The registered person shall having regard to the number and needs of the service users ensure that— (a) the physical design and layout of the premises to be used as the care home meet the needs of the service users; (b) the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally; (j) there are provided at appropriate places in the premises sufficient numbers of lavatories, and of wash-basins, baths and showers fitted with a hot and cold water supply; (k) any necessary sluicing facilities are provided; (l) suitable provision is made for storage for the purposes of the care home; 5. YA34 19 1(a-b) Sch 2 (a-b) The environment and facilities provided must meet the required minimum standards. 19 Fitness of workers (1) The registered person shall not employ a person to work at the care home unless— 30/04/07 Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 29 (a) the person is fit to work at the care home; (b) subject to paragraphs (6), (8) and (9), he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2; SCHEDULE 2 INFORMATION AND DOCUMENTS IN RESPECT OF PERSONS CARRYING ON, MANAGING OR WORKING AT A CARE HOME 2 Details of any criminal offences— (a) of which the person has been convicted, including details of any convictions which are spent within the meaning of section 1 of the Rehabilitation of Offenders Act 1974 and which may be disclosed by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions Order) 1975; or (b) in respect of which he has been cautioned by a constable and which, at the time the caution was given, he admitted A CRB application and POVA check must be completed before a newly appointed member of staff can commence their duties. Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 30 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. 2. Refer to Standard YA12 Good Practice Recommendations The providers’ should continue to improve and develop the social and recreational opportunities for services users that reflect their preferences, choices and interests. Good and reliable formalised quality assurance measures should be in place. YA39 Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 31 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Caritate Nursing Home DS0000068035.V330852.R02.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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