CARE HOMES FOR OLDER PEOPLE
Mount Pleasant 18 Rosemundy Lane St Agnes Cornwall TR5 0UD Lead Inspector
Lynda Kirtland Announced 23 June 2005 09.30 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 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 Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Mount Pleasant Address 18 Rosemundy Lane St Agnes Cornwall TR5 0UD 01872 553165 01872 275289 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Godfrey William Sear & Mrs Susan Ann Sear Care Home2 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: none Date of last inspection 11 Feburary 2005 Brief Description of the Service: Mount Pleasant is a care home located near the centre of the village of St. Agnes. The registered providers are Mr G Sear and Mrs S Sear. The home is close to all local amenities with access to transport links into the main town of Truro. Mount Pleasant provides accommodation and personal care for up to 22 older persons. The accommodation for service users and the communal areas are on one level; there is full access around the home for all service users. Corridors are wide to suit service users who use a wheelchair. The first floor accommodation is for staff, and a member of staff sleeps in on call in the upstairs accommodation.There are 20 rooms of which 18 are for single occupation and two shared rooms. The majority of service users’ bedrooms have an en-suite toilet and washbasin facilities. Communal areas and service users’ rooms are decorated and furnished to a good standard. The kitchen area has been upgraded and was clean and well ordered. The house is set in well laid out gardens, with fine views of the town and countryside. There are parking spaces to the front of the property. Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Two inspectors visited Mount Pleasant on the 23 June 2005 and spent the day at the home. This was an announced visit. On the day of inspection 19 residents were residing in the home. The inspector met with 11 residents and 3 representatives, a number of staff and the registered provider to gain their views on the service that Mount Pleasant provide. The inspector also received comment cards from 2 residents and a representative, which summarised their views on the care that the staff at the home provide. At the time of the inspection the registered provider gave the inspector their pre inspection questionnaire this document is similar to a questionnaire on how they are managing the home. In addition the inspector examined records, policies and procedures and toured the building. This report summarises the findings of this inspection. What the service does well: What has improved since the last inspection?
Since the last inspection the registered provider has worked to address eight areas of improving standards of care within the home that were identified in
Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 Page 6 the previous report. The registered provider and staff have developed and improved the following areas of care: developing an informative homes statement of purpose and residents guide, which informs residents of the services and facilities that Mount Pleasant provide. The registered provider has developed various documentation that now evidence the homes positive relationship with health professionals and what health care residents receive in the home. From inspecting the accident book it is noted that the number of falls is minimal, and the steps the home takes to minimise further falls. The registered provider has employed a domestic so that care staff now have more time to undertake care tasks. The registered provider has also given residents a choice if they want to have a lock on their room to promote further privacy. The registered provider and staff have developed care plans significantly. Further development to this area of work is needed to provide staff with the information they require to meet individual needs of residents. Residents and their relatives were in the main complimentary about the care that the home provides. The inspectors were not concerned by the level of care or the observed staffs interactions with residents throughout the inspection. What they could do better:
At the last inspection 26 requirements were identified of which the registered manager has complied with eight. Therefore 18 requirements are re notified to the home. From this inspection a further seven requirements have been identified. The registered provider and staff must improve in the following areas of care; to develop a pre admission assessment, which ensures that resident’s needs are identified and clarifies that the home can meet their individual care needs. The home must continue to develop the care planning and review process in order that individual care needs are identified to enable staff to approach the individuals care need in a consistent manner. Resident’s social, educational and leisure pursuits must be identified and promoted in the home. Staff must attend updated training in the homes medication procedure to ensure the safe receiving, storage, administration and disposal of medication. The homes complaints process must be promoted to ensure residents and their representative’s feel able to raise any concerns, be listened too and that there will be no repercussions on their care. The adult protection policy must be amended to ensure that correct procedures for instigating adult protection concerns are carried out correctly. All staff must receive training in this area. The registered provider must ensure that recruitment checks are carried out satisfactory. Staff access to training, supervision and appraisal’s must occur to promote and encourage updated working practices in the home. The registered provider must ensure that the homes records are in line with regulations and reviewed annually. Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 Page 7 Due to the level of concern surrounding the number of requirements that have been re notified to the home, in some occasions for the third or fourth time, CSCI will meet with the registered provider to discuss the importance of this further and to explain the possible legal consequence if positive arrangements are not put in place. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,5 Mount Pleasant has detailed information, which informs service users and their representatives about the services that they provide. No progress has been made to improve the admission procedure to ensure that there is a proper assessment prior to residents moving into the home. The home also experience difficulties in obtaining assessments that have been completed by statutory agencies. This makes the assessment arrangements unsatisfactory. Service users experienced a positive introduction to the home. EVIDENCE: The registered provider has updated Mount Peasant Statement of Purpose and Residents Guide to reflect the services that they provide. The registered provider agreed to review the presentation of these documents so that they can be accessible to a larger audience. The inspectors saw a blank template of Mount Peasants statement of terms and conditions between the home and residents. This met the requirements of the national minimum standards. However the registered provider stated that signed copies of these documents are not kept on the homes premises. The
Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 Page 10 inspectors requested that all paperwork relating to the home is available for inspection. From inspection of residents files there was no documented evidenced that a pre admission assessment had taken place. The registered provider stated that she ‘threw away’ her notes when she had transferred the information to the residents care plan. The inspectors stated that all information in relation to the pre admission process must be kept. From inspection of four residents’ files the registered provider agreed that information from referring agencies is also lacking to assist in the pre admission assessment. The consequence of this is that the home admits residents with partial knowledge of the individuals’ physical, emotional, social, educational and leisure needs. The registered provider agreed that she would attempt to address this with relevant referring agencies. From discussion with residents and their representatives, it was evident that they are involved in discussions before admission to the home. The registered provider said that the home aims to meet with the prospective residents prior to admission in the community. A months trail period is offered to all new residents after which a review is held with all parties present to consider if the placement is appropriate and if so a long-term placement will be provided. Residents and their representatives commented that they felt that they received a ‘nice welcome’ to the home. Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Care plans need to be more detailed to make sure that resident needs and choices are met. Residents’ health needs are met in a satisfactory manner. The staff at the home aim to build positive relationships with residents that are based upon the resident’s dignity and privacy. EVIDENCE: Since the previous inspection the registered provider and staff have developed care plans significantly and they now show more clearly individual care needs. They still need to be developed further so that the individuals care plan accurately describe what skills residents are able to self manage and where staff interventions are needed to approach a specific care need and meet the preferences and choices of residents. The care plan must also include social, educational and leisure needs. The arrangements for care planning and risk assessments for residents need to be reviewed and developed further. From discussion with residents and their relatives they were unaware of their care plans and commented that they had not been involved in their development or subsequent review. From discussion with residents they commented that they felt that they received satisfactory care.
Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 Page 12 Positive links are maintained with the local primary health care services The General Practitioners and District Nurses visit the home when needed. Residents stated that they felt that all their health needs were identified, appropriate action taken, and follow up treatment provided by the home and local health services was ‘good’. The previous inspection required that the home audit the number of falls and ensure that appropriate risks assessments are in place to minimise falls. Since February three falls have been recorded. The inspectors concluded that this requirement has been complied with. Specific equipment for example to assist in moving and handling of service users are available in the home. The inspector observed a medication round which was carried out by a knowledgeable member of staff. The inspector observed her administering medication appropriately and completing the MAR sheets. She confirmed that all staff needed to attend a refresher course in the safe handling of medications. The inspector requires that some improvements in the recording of medication is undertaken as follows: the inspector was unable to audit the medication via a tablet count cross referencing with the MAR sheets as the medication the home had received had not been recorded on the MAR sheets, this must be recorded; transcribing of medication must be signed by two members of staff; permission from residents in how they want their medication to be managed (either self administer or via the home) must be sought and incorporated in their care plans; a risk assessment must be undertaken for those residents who self administer their medication; staff must be aware of where the medication policy/procedure is located so that they can refer to it. Currently the home has no prescribed controlled drugs, if this occurs appropriate storage facilities must be installed. Mount Pleasant outlines in its statement of purpose and service users guide its philosophy on promoting service users rights, privacy and dignity. Inspectors noted that the atmosphere of the home and residents appeared to be relaxed. Residents and their relatives commented the majority of staff ‘were ‘kind’. From inspectors observations of staff throughout the inspection it was noted that staff approached and interacted with service users in a professional yet sensitive manner. Residents confirmed that they have a choice as to when to rise/ retire to bed, receive their mail unopened, have access to a private phone and can receive visitors in private. Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 Mount Pleasant provides a limited programme of activities to promote and encourage the pursuit of residents social, educational and leisure needs. Flexible visiting arrangements are in place and visitors are welcomed at the home. EVIDENCE: From discussion with residents there was a variation in view about the level of activities in the home. Some felt there was ‘enough to do’ and others felt that the level of activities was lacking. Residents recalled the weekly activities as keep fit and a sing-along. In discussion with the registered provider she commented that the home have attempted to organise outings which have later been cancelled by residents. The home has organised a concert to which residents and the community are invited. The registered provider agreed to discuss with residents the level of activities in the home and how this can be improved. Social, educational and leisure interests must be included in residents care plans as this is currently not occurring. There is a flexible visiting policy and residents determine where they meet with their guests. Visitors commented that they are welcomed to the home. As the home recently had an Kitchen Environmental Health Inspection this was not inspected. In the mains residents were complimentary about the quality of food.
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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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Mount Pleasant has an appropriate complaints and whistle blowing policy. Some residents are confident to raise any concerns with staff. The policy and procedure for protecting resident against abuse needs to be improved. EVIDENCE: Mount Pleasant has an appropriate complaints procedure that is included in the homes statement of purpose and service users guide. CSCI have received one anonymous complaint around the provision of food, which was partially upheld since the last inspection. The home has not received any complaints. Residents discussed with the inspector how they could address their concerns. The inspector discussed with the registered provider how residents might find it difficult to raise concerns with staff for two reasons. Firstly as mainly family members staff the home and secondly due to this some residents voiced anxiety that there may be repercussions on their care. The registered provider stated this would not happen and agreed with the suggestion of holding a residents meeting to give a opportunity to share views and provide reassurance that repercussions on care will not occur. The arrangements for protecting residents against any form of abuse remain in the process of development. The registered provider agreed to ensure that the policy is written in line with POVA, DOH ‘No Secrets Guidance’ as well as the Local Authorities Adult Protection Procedure. Two previous requirements for the registered provider to arrange for staff to attend training in the area of abuse have not been complied with. This is re notified to the home. Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 Service users are satisfied with their private accommodation. EVIDENCE: From discussion with residents all were satisfied with their accommodation and could not think of any improvements in this area. The previous requirement to provide locks on doors if appropriate has been complied with. The environment was inspected in detail at the last inspection and was viewed as providing satisfactory and comfortable accommodation. The inspectors did not observe any environmental issues on this visit to the home. Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Mountford House ensures that sufficient staffing levels are present in the home at all times. The recruitment checks are not carried out as required by regulation. Staff training must be developed to ensure that their awareness of older persons care is developed and put into practice. EVIDENCE: From discussion with residents and staff plus inspection of staff rosters, it is evident that there are sufficient staffs on duty at all times. The registered providers must record the hours they have worked at the home, which will also clarify for staff their availability. Staffing ratios are 1:6 in the mornings and 1:9 in the evenings plus extra carer for teatime assistance. Since the last inspection a cleaner has been employed at the home. From discussions with staff and the registered provider there has been reluctance for staff to attend NVQ training. The registered provider has discussed with newer staff the need to undertake this training and 4 members of staff are now considering this. The registered provider is aware that resident’s needs are becoming more complex, for example in the area of memory loss. Therefore the inspector identified that staff must gain training to update their knowledge and practice in older persons care. Individual training profiles must be introduced. Some mandatory courses for all staff must occur. The home has suitable recruitment procedures. From inspection of staff files it was evident that not all recruitment checks are taken prior to employment. These must occur i.e. two references, CRB/POVA must be gained prior to employment. Staffs’ statement of terms and conditions of employment is now kept on the individuals file and therefore compliance with this previous requirement has been met.
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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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37 There is an absence of training for the registered provider and staff team. To promote good working practices the promotion of training and supervision must occur for the benefit of staff skills and the residents who receive care in the home. Residents have stated they would like to be more involved and consulted about the services that the home provides. A lack of documentary evidence supports this. Records in the home must be reviewed annually to ensure that they are accurately reflect the services and processes that the home provides and promotes. EVIDENCE: The registered provider has worked in the social care area for 30 years. The registered provider has not attended the Registered Managers Award or any updated training. She must update her training to ensure that the home is aware of and undertakes care taking into account recent research and new working practices.
Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 Page 18 Residents commented that in the main they felt the care they received at the home was ‘good’. Some residents commented that they would like to be consulted more about the homes facilities/ provisions. The registered provider in discussion with the inspector agreed to reinstate the residents meeting to use this as a forum for gaining views. The registered provider has implemented a quality assurance survey for residents in June 2005 to attempt to gain residents views on the services the home provides. The registered provider agreed to send its findings and any actions it intends to take to CSCI. The registered provider showed the inspector an appropriate new format to record supervision. Individual supervision will in future be recorded on this document. Yearly appraisals also need to be re introduced. The registered provider has induction books for staff but on inspection these were not completed. Records held by the home are stored in a confidential manner and in line with the Data protection Act. Staff and service users records must be developed further to meet the requirements of the national minimum standards. The home s policies must be reviewed on a yearly bases to ensure that they still reflect the practices of the home. Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 Page 19 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x
COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 1 2 2 x x 1 2 x Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14, Sch 3.1 15(1) Requirement The registerd person must assess all service users before they are admitted to the home. Fifth notification Care plans must be developed further to ensure that they inform, guide and direct staff in the interventions needed to provide specifc care. The registerd person must: i) keep the servie users plan under review in consultation the service user and/ or representative. ii) make the service users plan available to the service user and /or representative and notify them of any revision. (Fourth notification) staff must be aware of the location of the homes mediaction policy at all times Medication received into the home must be recorded appropriately and transcribing of medication must be signed by two staff members. Staff must attend a refresher course in the safe handling of medicines and moving and handling. Timescale for action 30/10/05 2. OP7 30/10/05 3. OP7 15, Sch 3.1(b) 30/10/05 4. 5. OP9 OP9 13(2) 13(2) Sch 3(i) 30/08/05 30/08/05 6. OP9/OP30 18(1) (c 30/11/05 Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 Page 21 7. OP9 12(2)13(1 )(b) 8. OP9 9. OP12 10. OP16 11. OP18 12. OP29 13. OP29 14. OP29 15. OP29 16. OP30 a risk assessment must be undertaken for those service users who wish to self administer medications. 12(2) service users wishes in the adminsitration of medication must be incoprated in their individual care plan. 16(m)(n) Service users social, educational and lesiure pusuits must be included in their individual care plan and actively pursued., (third notification) 22(3) the registered provider must consult serivce users to promote the complaints process and provide reassurance that there will be no repercussions on their care provision. 13(6) the registerd provider must 18(1)(c ) ensure that all staff at the home are aware of the adult protection policy and procedure and attend relevant training in this area. (third notification) 17(2)Sch The registered person must 4.6 retain in the care home the staff records listed in Schedule 4.6 (second nortification) 19(1) The registered person must Schedule obtain Criminal Records Bureau 2.7 disclosures for all persons employed. (second notification) 19(1)Sche The registered person must dule 2.7 provide a list to the commission of the disclosure numbers of all persons currently employed. (second notification) 18(4) The registered person must provide all persons employed in the home with a copy of the General Social Care Council code of practice for social care workers.( second notification) 18(1) 12 Staff who prepare food must (1)(a) have a current food hygiene certificate.
D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc 30/09/05 30/10/05 30/10/05 30/11/05 30/12/05 30/11/05 30/09/05 30/09/05 30/11/05 30/12/05 Mount Pleasant Version 1.20 Page 22 17. OP30/04 18. OP31 19. OP31 20. OP32 21. OP33 22. OP36 23. 24. OP37/OP2 18(1)(a)(c Individaul staff training and )(i) development assessments and profiles must be introduced and kept in respective staff files. A written annual training progrmamme must aslo be established. (second notification) 7,8,10(1), The registered provider must be 18 on duty in the home on the basis of a full time post or employ a registered manager as a full time post. The provider must confirm in writing to the commission how they intend to address this issue. The registered provider must include on the staff roster the hours they are on duty or provide other evidence of how much time they spend on duty in the home. Fourth notification 10(3) The register provider must demonstrate that she has undertaken periodic training to update her knowledge/skills, competence and experience in the managing the home.Second notification 24(3) 16 Service users and their (m)(n) representatives must be consulted about the operation of and services provided in the home. Third notification 24 The findings of the quality assurance survey and the actions taken must be forwarded to the CSCI. Third notification 18(2) Staff must receive formal recorded supervision at least six times per year. Supervision should cover all aspects of practice, philosophy of care and career developmental needs.Fourth notification 17, sch Records must kept on the homes 2,3,4 premises and in adherance to Schedule 2,3 and 4 30/12/05 30/09/05 30/10/05 30/09/05 30/09/05 30/09/05 30/08/05 Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 Page 23 25. 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. 3. Refer to Standard OP16 OP38 Good Practice Recommendations The complaints policy should be amended to state that complaints could be made to CSCI at any time. All policies and procedures should be signed and dated, and reviewed annually. Mount Pleasant D52-D04 S8913 Mount Pleasant V220943 230605 Stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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