Inspection on 10/01/08 for Mount Carmel Residential Home

This inspection was carried out on 10th January 2008.

CSCI found this care home to be providing an Adequate service.

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

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Mount Carmel Residential Home 88 Church Lane Leeds West Yorkshire LS15 8JE Lead Inspector Paul Newman Key Unannounced Inspection 10th January 2008 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 Residential Home DS0000070795.V357265.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 Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mount Carmel Residential Home Address 88 Church Lane Leeds West Yorkshire LS15 8JE 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) 0113 2644441 Mount Carmel Care Ltd vacant post Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC; to service users of the folowing 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: 13 1 August 2007 2. Date of last inspection Brief Description of the Service: The home is located in the Crossgates area of Leeds. It is a detached house close to local shops, churches, pubs and services. Local bus services are just a few yards from the home. The home can accommodate up to thirteen service users who have no specialist care needs. Nursing care is not provided but the home is supported by local health care services. Bedrooms are on three levels and all can be accessed by a passenger lift that has been fitted in a new extension. Six bedrooms are en-suite one of these being a shared room. Information about the home is provided in the form of a statement of purpose and service user guide. Both these documents are available at the home and should be regularly updated by the home and should outline the terms and conditions for residents. The homes weekly charges are £397. This does not include hairdressing or private chiropody. The figure was provided at the time of the inspection on 10/01/08 and is subject to annual review. Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced visit carried out by one inspector that started at 9:30 and finished at 13:30 on 10 January 2008. The home had been inspected in August 2007 at a time when the CSCI was processing the application of a new Registered Person. When the process is completed, because there is a new owner/ person in control, the CSCI makes a key inspection within six months of the approval of the application. The purpose of this inspection was to make sure the home was operating and being managed effectively by the new person in control, for the benefit and well being of the people who live there and that the outcomes for the people meet National Minimum Standards. Before the inspection, information collected about the home since the last inspection was reviewed. This included looking at any reported incidents, accidents and complaints. There had been few reported incidents and no complaints and the group of people living at the home was largely the same as last time, so no surveys were sent out on this occasion. It was planned to have more personal contact and conversation with people during the inspection visit. The manager provided information before the last inspection visit that was summarised in the Annual Quality Assurance Assessment (AQAA). This is a self-assessment of the service and gives a lot of information about how the manager/owner thinks the home is meeting standards, how it has improved during the last year and what further improvements are intended in the year ahead. This was used to check progress on areas the home said it was going to improve. A number of documents that the home must keep up to date were looked at during the visit. All areas of the home used by the people who live there were checked. Time was spent talking with the people, watching what was going on, as well as talking with the deputy manager and some of the staff on duty. The manager was only spoken with briefly since she was already committed to taking a person out to deal with some banking. Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Five requirements are made. These represent issues where the home does not fully meet National Minimum Standards. • The written information about the home was out of date and did not accurately reflect the services and facilities. The owner and manager must get on with reviewing this and the service user guide so that people interested in living at the home have the right information to make an informed decision about whether the home is suitable for them. Some things remain outstanding with the environment but the CSCI is aware that there are now plans to put this right within a building project to improve the facilities and extend the building. The owner said he DS0000070795.V357265.R01.S.doc Version 5.2 Page 7 • Mount Carmel Residential Home expected work to start in the next three months but must write to the CSCI confirming a start date and projected timescales so that the CSCI can monitor things. • There is an urgent need for training updates in moving and handling and the training must be aimed at meeting the specific needs of the current group of people. There may also be implications for equipment to assist staff and this must also be considered in the light of the training provided. The manager must get on with making application to be registered with the CSCI. The Registered Person must write a report about the conduct of the home every month and send a copy to the CSCI. These reports help the CSCI keep up to date with what is happening and able to monitor that improvements are being made. • • Some recommendations are made to improve practice in the detailed recording of daily living tasks for each person, a flow chart for safeguarding procedures and the organisation of staff personnel files. 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 Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 does not apply to this service. People who use the service experience adequate quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. Written information about the home is available but this is not currently up to date for people to make an accurate and informed decision about whether the service and facilities are right for them. Peoples’ needs are properly assessed before admission. EVIDENCE: Although there was a Statement of Purpose on display in the entrance hall of the home, this still reflected the previous owner, previous staff employed including the old manager, and facilities that were out of date. The registered person must get on with reviewing this, together with the service user guide so Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 10 that people interested in living in the home are given accurate written information to assist them in making a decision about whether the home is suitable for them. The documents must contain all the information that is set out in National Minimum Standards and the Care Homes Regulations. Despite this, it is standard practice at the home that all people considering coming to live at the home and their relatives are seen personally. A visit to the home is arranged when at least the relatives and, if possible, the prospective service user can see the room available, general facilities and meet other people living there. From the discussions with the deputy manager and checks made of two files it showed that pre admission assessments are made before people come to live at the home. The two files checked were for people who had been recently admitted. The AQAA said that improvements had been made in making the assessment to make sure that information is accurate and up to date. Apart from the home’s own assessment documentation, other information is gathered from any social worker or healthcare professionals that have been involved. From this information, if the home believes it can meet the person’s needs, a plan of the care needed is written. Once living in the home, individuals’ progress is monitored to make sure that care needs are met. Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. The care plans provide clear instructions for staff to follow making sure that health and personal needs are met. The people at the home are treated with respect and dignity. EVIDENCE: Two files were checked to see if the recommendations made in the last inspection report had been acted upon. This was about including a more detailed assessment for daily living. This is a useful ‘person centred’ approach and gives staff a lot of more detailed written information about a person’s likes, dislikes and personal preferences. The files that were checked showed that care plans are drawn up and reviewed regularly. The plans are based on a pre admission assessment carried out by the manager and/or deputy and other information like easy care documentation and the two files checked Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 12 showed that the care plans that had been written accurately and all the persons needs had been identified. The more detailed assessment for daily living still needs to be worked upon. It is this detail that fully evidences that staff are aware of peoples’ preferences and choices, although in speaking to people at the home, watching what was going on and speaking to staff, it is clear that they know the people they care for very well. Improvements have been made in the daily recording for specific care needs like catheter care. There were appropriate risk assessments that included moving and handling, mobility and nutrition. Health care needs were identified and files showed that regular visits are made to the home by a chiropodist, dentist, optician and community health services. All of the CSCI surveys returned last time said that people were very happy with the care provided and that relatives are kept informed and up to date with important issues. There were positive comments about the caring qualities of the staff and people spoken with during this visit once again commended the staff. No changes were reported to medication practices and procedures. The drugs administration charts were checked and were error free and the medication was stored securely with no overstocking of drugs. It was an unusual day because the main windows of the dining room and lounge were being replaced so there was a little upheaval for people to put up with, but they were taking this in their stride and were well supported by the staff. In the time spent watching what was going on, the staff seemed organised and efficient in making sure people got the attention and care they needed. Staff were personable and professional and relationships appeared good with some friendly banter from time to time. There were examples of good practice in making sure that peoples’ dignity was maintained. Clothing was clean and all of the residents looked well cared. Staff were careful to make sure doors were closed at times when personal care was delivered and were seen knocking on doors before entering rooms. They were attentive to people and some overheard conversations showed staff to have a nice manner that people appreciated. Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. Peoples’ social expectations and personal preferences are met and they are able to exercise choice in their lifestyles so they can be as independent as they can. People living at the home are provided with a varied and nutritious diet so they can eat healthily. EVIDENCE: No changes were reported. Conversations once again found people to be very happy with the range of activities provided. The comments made during this visit reinforce the good work and successful encouragement in getting residents active and involved. There is a programme of activities that includes both in-house things as well as trips out like pub lunches and shopping trips to the nearby Arndale Centre. The home regularly takes local students for work placements and on the day of the visit two students were spending time chatting with people. This is a useful addition to staff time and people appear to really enjoy the attention of the young people. A volunteer continues to Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 14 come in twice weekly to organise activities and was visiting on the afternoon of the inspection visit. The discussions with staff and conversations with people they care for once again showed that individual likes, dislikes and preferences are known. This includes getting up and going to bed when you wish, what you wear each day, the foods you like or don’t like, whether you want to spend time alone in your room and what activities you get involved in. Some people spend time together in bedrooms chatting and watching TV and have built good friendships. People are encouraged to express their views and choices about the food provided on a daily basis. The people spoken with on the inspection visit confirmed that the food was good and they had enjoyed the lunchtime meal. Staff were seen giving good sensitive support and encouragement to those people who needed assistance. This was particularly important, as the dining room could not be used because the main window being replaced, so the lounge ‘doubled up’. Although a bit cramped for space people entered into the spirit of the situation and there was some good humour about it all. Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 15 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): 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. The people who live at the home and their relatives know how to complain and feel confident that they will be listened to, and that appropriate action will be taken when necessary. There are adult protection procedures that staff are aware of and understand. People can be assured that they can feel safe at the home. EVIDENCE: The deputy manager said that the home encourages people to air views and concerns at an early stage so that staff can act upon this and resolve things quickly. It is was clear from the conversations with people living in the home that they feel that all the staff are very approachable. People said that any requests were always listened to, but they had no reason to complain because they were treated so well. There have been no complaints since the last inspection. Policies and procedures are in place for the protection of vulnerable adults and staff have been given training on this. The training includes indicators of abuse and whistleblowing. A recommendation made in the last inspection Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 16 report that a simple ‘flow chart’ is made that includes a simple step by step procedure of what to do if abuse is reported or suspected, that includes telephone numbers of the organisations that need to be contacted including the out of hours duty social worker, still has to be fully completed. Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 17 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): 19 and 26. People who use the service experience adequate quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. People living at the home live in a clean, comfortable and safe environment that has significant improvements and refurbishment planned. EVIDENCE: On the day of the visit, the co owner and registered person in control, was at the home assisting a builder to replace the windows in the dining room and lounge. He reported that the plans for a new extension and improvement of the existing facilities, including all the issues raised in previous inspection reports, had been finalised. Some final amendments had been made to the plans following a recent meeting with the Fire Officer. Finance has been agreed with the bank and the owner fully expects work to begin in the next Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 18 three months. As part of this project a new kitchen is planned, additional communal and office space as well as additional bedrooms. The project will also see the driveway and car parking area with a firm tarmac finish, garden improvements and existing windows replaced. Some of this work is long overdue but matters were protracted and complicated following the death of the previous owner. When this work is nearing completion the owner will make application to the CSCI for these improvements and the extension to be registered. The CSCI Regional Registration Team will deal this with. A lower ground floor room that was previously an office was being converted to an additional bedroom at the time of the last inspection. This is now complete and registered with the CSCI and has increased the home’s registered occupancy. The home was successful in being awarded a Local Authority improvement grant and has now improved the lower ground floor bathroom including installation of a much needed walk in assisted bath. Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 19 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): 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. People living in the home are cared for by experienced staff who are trained in safe working practices, but moving and handling training must be updated. EVIDENCE: The duty rotas were seen and from watching what was going on, there certainly seemed to be enough staff on duty who were assisted by two young people on work placements from a local school, and later, a volunteer who organised activities. People were getting good attention from staff and good support at times when they needed personal care. People once again made positive comments about the caring qualities of the staff and the relationships were warm, some people describing things as just like living at home with your own family. Personnel records were checked at the last inspection when it was found that the home makes sure that the appropriate checks are made and other documentation that must be sought before someone starts work is completed. There have been no new appointments made since then, so no further checking was done during this visit. Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 20 The home exceeds targets set for the number of staff who should have a National Vocational Qualification (NVQ). The last inspection report noted that some training updates were planned in the autumn of 2007 after the peak holiday period. In the discussion with the deputy manager about one person’s mobility problems following illness, it was clear that staff may well compromise themselves and the person they are assisting in moving and handling. There is an urgent need for training updates in this area and the training must be aimed at meeting the specific needs of the current group of people. There may be implications for equipment to assist staff and this must also be considered in the light of the training provided. The owner and manager need to review all of the training that has been provided and be very sure it is appropriate and up to date to meet the care needs of the people living at the home. Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 21 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): 31, 33, 35, 37 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. To be within the law, the manager must make formal application for registration with the CSCI. The opinions and interests of the people are central to the way the home is run and there is a clear approach to resident care that is person centred and is the focus of staff practice. Safety checks and systems of communication make sure that the home is a safe place to live. Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 22 EVIDENCE: The person appointed as manager last year has worked at the home for a long time and has the Registered Manager’s Award but has yet to make a formal application the CSCI for registration. There appears to be no specific reason for an application not being made and there must be no further delay as this is breaking the law. As was seen on the day of the visit, the Registered Person is almost a daily visitor to the home and is fully involved with things. He was assisting a builder replace the dining and lounge windows. The deputy manager said the involvement of the owner was helpful and appreciated. Although the owner started sending monthly reports to the CSCI about the conduct of the home (that are required by regulation), these have not been sent in recent months. These reports help the CSCI keep up to date with what is happening and able to monitor that improvements are being made. The last inspection report noted that the manager was implementing a quality assurance system that is based on National Minimum Standards. In her absence this was not checked but will be next time. The home has conducted its own satisfaction survey that indicated a high degree of satisfaction from the people living there and from their relatives. The system of keeping money for people for safekeeping remains unchanged, but a further random check was made of one person’s records with the cash kept. This was sound. Issues about the need for updates in moving and handling training and the possibility of additional equipment to assist staff are noted above, but in other respects, staff were seen to be wearing appropriate protective clothing to prevent cross infection and safety checks are made of the facilities and equipment to make sure the home is a safe place to live. The housekeeper does well to make sure the home is clean and free from unpleasant odours. With the building work going on, staff were careful to make sure residents were away from areas that might be dangerous and made sure there was plenty of heat. Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 23 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 1 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 X X 3 Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 24 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 and 5 Timescale for action The Registered Person must 01/04/08 compile a statement of purpose and service user guide that have all of the required information, is accurate and up to date and must make this available to people interested in living at the home. This will help people make an informed decision about whether the home is suitable for them. The owners must write to the 30/04/08 CSCI confirming when building works start on the new extension and to address outstanding issues from previous inspection reports and must outline timescales for the completion of these. The improvements will make the home a better place to live and will meet National Minimum Standards. The Registered Person must 28/02/08 urgently arrange for moving and handling training for the staff. The training must be aimed at meeting the specific needs of the DS0000070795.V357265.R01.S.doc Version 5.2 Page 25 Requirement 2 OP19 16 and 23 3 OP30 18 Mount Carmel Residential Home current group of people. Confirmation of these arrangements must be made in writing to the CSCI. There may also be implications for equipment to assist staff and this must also be considered in the light of the training provided. This will make things safer for staff and any person being assisted and this is the Registered Person’s legal responsibility. The manager must make 28/02/08 application for registration with the CSCI. This will make sure the CSCI can assessed the manager is competent and the home is operating within the law. Outstanding from inspection report of 01/08/07 The Registered Person must 28/02/08 write a report about the conduct of the home every month and send a copy to the CSCI. These reports help the CSCI keep up to date with what is happening and able to monitor that improvements are being made. 4 OP31 9 5 OP37 26 Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations To develop a more ‘person centred approach in the care planning documentation the manager should reintroduce the assessment for daily living for all people using the service. It is recommended that a simple ‘flow chart’ is made that includes a simple step by step procedure of what to do if abuse is reported or suspected that includes telephone numbers of the organisations that need to be contacted including the out of hours duty social worker. The staff personnel documentation should be kept in organised files rather than loosely in a sling of a filing cabinet where there is a risk that things might go missing or get mislaid. 2. OP18 3. OP29 Mount Carmel Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Residential Home DS0000070795.V357265.R01.S.doc Version 5.2 Page 28 - 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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