Inspection on 13/06/07 for Mount Carmel

This inspection was carried out on 13th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mount Carmel 29/06/09

Mount Carmel 09/12/05

Mount Carmel 28/07/05

Mount Carmel 21/12/04

Mount Carmel 13/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mount Carmel Highfields Broadway Derby Derbyshire DE22 1AU Lead Inspector Steve Smith Key Unannounced Inspection 13 June 2007 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 Mount Carmel DS0000001994.V329451.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. Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mount Carmel Address Highfields Broadway Derby Derbyshire DE22 1AU 01332 553466 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) Sisters of Mercy Trustees Vacant Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th December 2005 Brief Description of the Service: Mount Carmel House is a single storey purpose built Home providing personal and social care for 20 people aged 65 years and over. The care Home is located off the Broadway in Derby. There are a number of small seating areas in the Home for the use of Residents and visitors, and a large dining room, which is also available as an activities room. There are 20 single bedrooms, all of which include a shower. Each bedroom is supplied with a staff call system, and all of the bedrooms meet the National Minimum Standards space requirements. The Home has a non-smoking policy, although smoking is permitted outside of the Home. Regular outings are arranged and activities regularly take place within the Home. The Home also has well set out gardens and outside seating areas. The charge made for a room at Mount Carmel Care Home is £355.00 a week, irrespective of the needs of the Resident. A copy of the Commission’s inspection report is available from within the Home. Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just over 7.5 hours. Discussion was held with two Residents, and the records of two Residents were ‘case tracked’. Discussion was also held with the Deputy Manager of the Home, and with one member of the care staff. A number of records were examined, and all of the bedrooms, and all of the public areas of the Home were examined. The Commission’s pre-inspection questionnaire, sent to the Manager, was examined. The Commission’s Residents questionnaire was also sent to a selection of Residents, and 10 were returned at the time of this inspection. They all commented most favourably on the Home, some extremely so. What the service does well: What has improved since the last inspection? Since the last visit made to the Registered Providers the statement of purpose had been improved, although further work was needed on this. The Registered Providers had also improved the terms and conditions of residency. The recruitment of staffing to the Home had also been greatly improved. The Registered Provider had ensured that the Safeguarding Adult procedure was in line with the procedure provided by the local Social Services Dept. Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 6 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. Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 7 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 Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 8 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 1, 2, 3 & 6. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. All new Residents moving to the Home were appropriately assessed prior to their admission, so that they were reassured that their needs would be met. EVIDENCE: The Registered Providers had provided a detailed statement of purpose for the Home, together with a Resident’s Guide, which was available in each Residents bedroom. However, the statement of purpose did not contain details of the physical environment Standards met/not met by the Home, and nor were they summarised in the Residents Guide. The Guide was well completed, and included the opinions of Residents on what life was like in the Home. The Residents Guide also contained information on how contact could be made with the Commission, the local Social Services Dept and the local Health Authority. Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 9 The records of two Residents were examined during this inspection and a complete copy of the statement of terms and conditions of residency or a contract, if purchasing their care privately, was found in each file. When new Residents were admitted to the Home, the Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each Resident, copies of which were seen. The Manager also assessed all Residents sponsored by Social Services Depts. If the Residents were self-funding from the outset, the Manager completed her own summary of needs, which were also seen during the inspection. Standard 6 does not apply to this Home. Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 10 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 7, 8, 9, 10 & 11. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents’ health and personal care needs were being well met, as demonstrated within care plans. Medication was administered appropriately to meet Residents needs, although improvements were required. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, Residents records were examined, for the purpose of case tracking. All of the basic information, concerning each Resident, was found to be in the files examined. That was, their name and date of birth, their preferred name, their next of kin, their GP, Care Manager and their date of entry to the Home. Records of the Manager’s initial assessment of each Resident were found in each file, together with Individual Plans of care for Residents. Records of the risk assessment on each Resident were also available. Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 11 The Manager had provided information within the files to say what additional needs Residents suffering with dementia might have had, and these were all reviewed at regular intervals. The files showed that very good records of events affecting each Resident were kept by the Home. However, the Manager did not provide formal reviews of Residents care needs at 6 monthly intervals, to which the Resident and their relatives could be invited, although the local Social Services Depts undertook formal review of care on an annual basis. All of the files were easy to read and good entries had been made by the care staff. The Deputy Manager said that the records of each Resident were reviewed at regular intervals by herself or the Manager, but records had not been signed to indicate that this had taken place. The files were well organised, with different sections and confidential records were maintained when this was felt to be necessary. Staff were appropriately maintaining the records of Residents health needs. All medication and the method of distributing it to Residents was examined. A good system was found to be in use, although the following two issues required attention: A review of some of the Medication Administration Record (MAR) sheets was undertaken and a number of signature gaps were found. The MAR sheets contained a number of handwritten entries completed by staff from the Home. These additional medications had not been signed by two staff, to confirm the correct entry had been made, and did not contain the name of the Doctor who authorised the medication, or the date on which the new medication was to start/had started. Discussion was held with Residents about life in the Home. They said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. They also said that their care needs were always met with dignity and respect. As a result, they felt very safe in the Home, and appeared to have a strong sense and appearance of well being – ‘They ask and make sure things are done my way, and ask and do this for my husband the way he wants things done. Staff are very, very good.’ ‘They made sure it is done exactly the way I want things done.’ Discussion was also held with Staff, and very positive ways were described of assisting Residents within the Home. Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 12 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 12, 13, 14 & 15. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents preferred lifestyles were respected by the Home, and Residents were given a wholesome and appealing diet in pleasant surroundings, that enhanced Residents well being. EVIDENCE: Residents were asked about the activities provided in the Home. They were able to say that Bingo was played, that a singer calls at frequent intervals, and that concert evenings were held. Residents also said that they were able to take part in the daily services held in the adjoining convent. A member of staff was asked about activities and she said that, in addition to the things already listed, that old films were shown and that Residents were assisted to walk around the grounds of the Home. Residents said that they decided when they got up and went to bed – ‘I can stop up as long as I like, and staff come and say would l like a cup of tea, if I am up late. I can get up when I want.’ Another Resident said ‘I shower daily, but staff would help me with this if I couldn’t do it on my own.’ Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 13 Relatives and friends of Residents were able to visit at any time, and could always be seen in private - ‘My family visit almost daily, and I can see them in private when I want to.’ A member of staff said that visitors could call at any time of the day and confirmed that Residents could always see them in private. Residents were able to say that the Home provided good meals and that a choice was available at breakfast, dinnertime and teatime meals – ‘Meals are lovely, a choice is available at every meal.’ ‘They go around the day before and ask you what you want the next day, for dinner and tea.’ Staff were able to confirm this. Staff also said that drinks and snacks were always provided between meals for Residents, which was witnessed during this visit to the Home, and that mealtimes were never rushed. Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 14 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 16 & 18. The quality in this outcome area was Excellent. This judgement was made using available evidence including a visit to this service. Complaints made to the Registered Provider/Manager were addressed to meet Residents needs. The protection policies and procedures provided meant that Residents were well protected. EVIDENCE: Residents said that if they had a complaint to make they would tell either the Manager or the Deputy Manager – ‘I would tell (the Manager or the Deputy Manager) and they would tell me the result after they have investigated.’ The Commission had not received any notice of complaint since the last visit to the Home, in February 2006. Since that visit, the Manager had recorded one concern raised by a Resident. This was reviewed and was found to have been satisfactorily dealt with. Good procedures were seen for both written and verbal complaints. The Registered Providers complaints procedure detailed that all complaints would be responded to by a Registered Provider within at least 28 days. The Registered Providers had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy. The Deputy Manager also had a copy of the Public Interest Disclosure Act of 1998, and of the Dept of Health’s policy called ‘No Secrets’ available in the Home. The Deputy Manager confirmed that all allegations and incidents of abuse would be promptly followed up and that all Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 15 actions taken would be recorded. So far, however, this procedure had not been needed. The policies and practices laid down by the Registered Providers ensured that all staff understood physical and verbal aggression by Residents. The Deputy Manager also said that a policy was available to staff stating that they could not benefit from Residents wills, which was also understood by the staff, with whom discussions were held. Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 16 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 19, 20, 21, 22, 23, 24, 25 & 26. The quality in this outcome area was Excellent. This judgement was made using available evidence including a visit to this service. The Home was very well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the entire Home, and including all of the bedrooms of the Residents. The Home was attractively decorated throughout, and the lounges and dining room were most pleasant to sit in, and were provided with appropriate items for the Residents. The bedrooms provided very good space and provision for each Resident. The Registered Providers had provided appropriate furnishings in all locations seen during this visit. Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 17 Toilets were easily available to all Residents, were clearly marked, and were provided with handrails where necessary. All bedrooms were also provided with a toilet and shower. A call system was also available throughout the Home. All bedroom doors were provided with locks, which Residents could chose to use. All radiators were appropriately guarded, and could be controlled within each bedroom. The Home had appropriate sluicing facilities, and laundry was washed at appropriate temperatures. Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 18 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 27, 28, 29 & 30. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Care staffing was provided to meet the needs of Residents. However, appropriate recruitment practices were not always followed when recruiting new staff to safeguard Residents welfare. EVIDENCE: A good level of staffing was found to be provided in the Home to meet the needs of Residents. At the time of this visit to the Home it was found that under 50 of care staff had a qualification of at least NVQ level 2 in Care: 6 out of a total of 15 care staff. However, the Deputy Manager was able to say that a further 3 staff were currently working towards obtaining the qualification, and it was anticipated that they would finish the course in August 2007 She therefore anticipated that more than 50 would hold an NVQ level 2 in Care by the end of August 2007. The records of the two most newly appointed members of staff, within the last 12 months, were reviewed to see whether the Manager had obtained all relevant information about them. It was found that almost all information had been obtained. However, a reference had not been asked for, concerning one of the new staff who had previously worked within the care profession in the past. This reference would have been in addition to the two references Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 19 submitted by the new member of staff. All other information was found to be satisfactory. The Deputy Manager said that new staff would be provided with induction and foundation training. She also said that all care staff were provided with at least three paid days training a year, and a member of the care staff provided corroboration, saying that much more paid training was provided. The records of some of this training was seen. All staff also had an individual training and development assessment and profile. Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 20 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 31, 33, 35, 36 & 38. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Management arrangements at the Home were very clearly in place to ensure that Residents care was maintained at a positive standard. EVIDENCE: At the time of this visit to the Home no Manager was in place, as the previous Manager had left at very short notice. The Registered Providers were found to be completing the formal ‘inspections’ of the Home, as required by Regulation 26, although the documentation of the visits were late in being presented to the Home i.e. visits were made to the Home on at least a fortnightly basis and details were taken to meet the requirements of Regulation 26, but no report had been presented to the Manager since February 2007. Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 21 The Deputy Manager was able to say that the Manager had started to address the Quality Assurance information needed in the Home, in that she ensured that an annual development plan was completed, copies of which were seen during this visit to the Home. Residents had completed questionnaires on the operation of the Home, as had relatives and friends of Residents, and so had District Nurses, but sadly none of this information had been published. A member of staff interviewed was able to describe the role of the keyworker to a Resident, which included understanding the slow deterioration of the Resident due to their age and other infirmities. The Deputy Manager was able to show that the personal money of Residents, held by the Home, was maintained satisfactorily. Staff were asked about the regularity of supervision in the Home. The staff said that this was provided approximately twice a year. The training required by the Regulations was examined. This showed that Moving and Handling training, Fire Safety training, First Aid training and Food Hygiene training and Infection Control training had been provided for all relevant staff, and this was confirmed by the staff spoken to. From copies of the Home’s maintenance schedule, forwarded to the Commission prior to the inspection, it was found that all necessary maintenance and repairs were being appropriately addressed. All Residents had been risk assessed to determine their vulnerability and measures had been put in place to provide protection where necessary. The Registered Providers had complied with all necessary legislation, such as the Health and Safety at Work Act 1974, and the Manual Handling legislation of 1992. The Deputy Manager was able to show that risk assessments on the working conditions of staff had been provided; that is for care staff, catering staff and domestic staff. She was also able to show that a written statement of the policy, organisation and arrangements for maintaining those safe working practices had been provided. Finally, the Deputy Manager was able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. With the assistance of the Fire Service, fire safety notices were also posted in relevant places around the Home. Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 22 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 4 4 4 4 4 4 4 STAFFING Standard No Score 27 4 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 4 Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4 Requirement Update the home’s statement of purpose to include a summary of the room sizes. (This issue is outstanding from the inspection report of 9 December 2005) Signature gaps on the Medication Administration Record (MAR) sheet must be followed up by the Manager/Deputy Manager. They should indicate on the back of the relevant MAR sheet why the gap occurred and their action when following this up. If an alteration or an additional medication is necessary on the MAR sheet, this must always be signed by two staff, dated and state the name of the Doctor authorising the change to the medication. 3. OP29 19 The Manager must ensure, when appointing new staff, that all the requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, as DS0000001994.V329451.R01.S.doc Timescale for action 08/08/07 2. OP9 13(2) 08/08/07 08/08/07 Mount Carmel Version 5.2 Page 24 amended during 2004, are obtained. In one staff’s records examined it was found that a reference had not been asked for from the care home/childrens home employer where the member of staff had worked at some point in their employment history. This reference would be in addition to the two named referees submitted by the member of staff. 4. OP33 24 Quality Assurance information must be completed on the Home, in that the questionnaires completed by Residents, their relatives and friends and by District Nurses must be published and made available to Residents, relatives and prospective new Residents to the Home. Supervision must be provided for all care staff. 31/10/07 5. OP36 18(2) 08/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP1 No. 1. Good Practice Recommendations The statement of purpose should contain information on the physical environment Standards met/not met and be summarised in the Residents Guide. Formal reviews of care should be undertaken at 6 monthly intervals. Those taking part should at least include staff from the Home, the Resident and their relatives, particularly the ‘personal representative’. The review of care should be shown to the Resident (or representative) DS0000001994.V329451.R01.S.doc Version 5.2 Page 25 2. OP7 Mount Carmel for signature. One of these reviews, each year, could be conducted by the Social Services Dept, although the Manager should provide formal written input to the review of the welfare and care provide to the Resident. When the Manager or Deputy Manager has reviewed a Resident’s file, they could indicate that this has been done by signing the record with a red or green pen. 3. OP12 Consideration should be given to employing an Activities Coordinator to increase the activities provided within the Home. The Registered Providers should ensure that at least 50 of care staff are trained to NVQ level 2 in Care at all time. Supervision should be provided for all care staff at least 6 times a year. 4. 5. OP28 OP36 Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT Commission for Social Care Inspection 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 Mount Carmel DS0000001994.V329451.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!