Inspection on 25/07/08 for St Anne`s Convent

This inspection was carried out on 25th July 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Anne`s Convent 31/05/06

St Anne`s Convent 18/01/06

St Anne`s Convent 06/06/05

St Anne`s Convent 17/02/05

St Anne`s Convent 31/08/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE St Anne`s Convent 92 Mill Road Burgess Hill West Sussex RH15 8EL Lead Inspector Annette Campbell-Currie Unannounced Inspection 25th July 2008 10:45 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 St Anne`s Convent DS0000014728.V367697.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. St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Anne`s Convent Address 92 Mill Road Burgess Hill West Sussex RH15 8EL 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) 01444 233179 01444 254603 stanneshomeltd@btconnect.com www.franciscan.co.uk Franciscan Missionary Sisters Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 19 male and /or female service users aged from 65 years, in the category of Old Age, not falling within any other category may be admitted/accom modated. 31st May 2006 Date of last inspection Brief Description of the Service: St Annes is registered with the Commission for Social Care Inspection to provide personal care for up to nineteen older people. The home is situated in Burgess Hill, close to a range of local amenities. The service is owned by the Franciscan Missionary Sisters, a religious order. The responsible individual acting on behalf of the order is Sister St Anastasia Mc Gonagle. The manager was appointed in April and is not yet registered with the Commission. The fees are currently from £358 to £400 per week. St Anne`s Convent DS0000014728.V367697.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 One Star. This means that the people who use this service experience adequate outcomes. Annette Campbell-Currie carried out the site visit for this key unannounced inspection over four and three quarter hours. The home had been without a registered manager for nine months before the appointment of the current manager in April. An application for registration has not yet been made. The newly appointed manager assisted with the site visit, all the information and paperwork we (the Commission) needed was available. There were sixteen people staying in the home at the time including two people having respite care. The manager designate returned an annual quality assurance assessment form (AQAA) however there was little information about the service and the care provided to help in the planning of the inspection. Surveys about the service were received from three people living in the home and four staff. The information has been used in making an assessment of the service. A tour of the communal areas, the bathrooms, laundry facilities and some bedrooms was carried out. The following documents were read: the case records for three service users, recruitment records for three staff, training records, staff rotas, the complaints records and other relevant information. The administration of medication at lunchtime was observed. During the day four people staying in the home were spoken with and two members of staff. The outcomes for people living in the home were assessed in relation to twenty-two of the thirty-eight National Minimum Standards for the care of older people, including those considered to be key standards to ensure the welfare of people living in the home. Eight requirements have been made following the site visit detailed in the section below ‘What the service could do better’. What the service does well: The home provides a well-maintained and peaceful environment for people. There are extensive grounds that provide a pleasant place for people to use in good weather. There is a chapel available for daily worship. The newly appointed manager is an experienced registered nurse and is committed to ensuring that the home meets the National Minimum Standards St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 6 and Regulations for Care Homes for older people. The staff are dedicated and committed to providing care in a sensitive and respectful manner. The food is home cooked to a high standard and people said it is very good and that they have a choice of meal. People spoken with said that the staff are kind and one person said that when she returned to stay in the home: “The staff gave me a wonderful welcome, it was like ‘coming home’”. What has improved since the last inspection? What they could do better: In order to ensure that the service is run efficiently and effectively meets with the regulations then good support must be provided to the manager and an application submitted for registration. The home must ensure that when the manager is not available assessments are carried out by someone qualified to do so, before a decision is made about the person moving to the home. A requirement has been made regarding this matter. Risk assessment should be carried out where a possible risk has been identified for example the safe use of kitchen facilities. A requirement has been made regarding this matter. People who are self medicating should have a risk assessment to ensure that they are able to understand and follow guidance and instructions. Controlled medication should be stored in a facility that meets the current guidance. Requirements have been made regarding these matters. All staff including the manager should attend updated training in safeguarding adults so that they are able to fully protect people and understand the reporting procedures. A requirement has been made about this matter. No care staff should begin work until an enhanced Criminal Records Bureau (CRB) or POVAfirst check has been received. A requirement has been made about this matter. St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 7 An induction and training programme that includes mandatory topics, moving and handling, food hygiene and fire safety, must be developed to ensure that staff have updated knowledge and skills. A requirement has been made regarding this matter. All policies and procedures required for the efficient running of the service should be available and reviewed so that the manager can ensure that staff understand and follow the guidance provided. A requirement has been made regarding this matter 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. St Anne`s Convent DS0000014728.V367697.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 St Anne`s Convent DS0000014728.V367697.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): 3 St Anne’s does not provide intermediate care. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It is not clear that all prospective service users have a thorough assessment of their needs before a decision is made about them moving to the home. EVIDENCE: The manager is experienced and qualified to carry out assessments with people before a decision is made about them moving to the home. She said that when she is on duty she makes sure that an assessment is carried out so that she can be sure that the home could meet the person’s needs if they decide to move in. At times when she is not available pre-assessments should be carried out by someone who is qualified to do so; it was not clear from the records seen and in discussion with the manager that this is always the case. Samples of case records were seen and showed that assessments had been St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 10 carried out when the person moved to the home; it was not clear that assessments had been carried out before a decision was made about the them moving to the home. People spoken with said they had made a choice about moving and had settled in well. Respite care is provided and some people have used this time to help them to recover following a hospital discharge, before they are ready to move back home. One person who had been discharged from hospital had not had a pre-assessment to find out what level of care she would need and whether or not this could be provided at St Anne’s. This issue was discussed with the manager who said that she would make sure no one would move to the home without a thorough assessment. A requirement has been made regarding this matter. St Anne`s Convent DS0000014728.V367697.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s health, personal and social care needs are set out in an individual plan of care. People’s health care needs are met. People who are self-medicating are not yet fully protected by the policies and procedures regarding medication. People are treated with respect and their right to privacy upheld. EVIDENCE: The manager has introduced a new system for care planning and review. The staff have been given training provided by the company that developed the system. Staff have begun completing the paperwork to make sure that each person’s needs are identified and documented. Samples of case records were seen and showed that some key information had been documented. The care plans included information about people’s health and personal care needs. There was little information about people’s life stories and preferred social activities. St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 12 Risk assessments had been carried out for some aspects of daily life including mobility, the risk of falls and mental health. The manager was advised to make sure that other aspects of daily life that could present a risk are identified and an assessment carried out, for example the safe use of a small kitchen. The importance of supporting people to maintain their independence within a risk assessment framework was discussed with the manager. It was clear that people spoken with value their independence and the support that staff provide. A requirement has been made regarding this matter. The manager was advised to make sure that clear guidance is provided to staff in the care plans about the way to support people; for example one person needed support in following an exercise programme to improve her independence and this was not documented. Another care plan noted that the person ‘can get distressed when things are not going to plan’ but there was no guidance about how to avoid this happening or how to support the person if they became distressed. The manager said that each person’s key worker takes responsibility for updating the care plan. A formal handover meeting is held at the end of each shift so that all the relevant information is passed on and also recorded in the daily record sheets. Copies of these notes were seen on case files. The manager said that she makes sure people’s care plans are reviewed and any change of need noted. Health care needs were noted and the manager said that a GP visits regularly for consultations that take place in private in people’s rooms. The manager has been liaising with the district nurse to make sure that someone recently discharged from hospital received the required medical support in the home. The manager said she would also contact the GP to discuss any physiotherapy input the person may need. The first priority for the newly appointed manager who is a registered nurse was to update the medication policies and procedures. She carried out an audit of the medication and established a training plan for staff to make sure they have the knowledge and skills they need to administer medication. Five staff have attended training and gained a competency certificate. A record book has been acquired for controlled medication and a lockable medication fridge has been obtained. Six people self medicate and have lockable facilities in their rooms. The manager was advised to ensure that risk assessments are carried out with those people to make sure they understand when and how to take their medication. A requirement has been made regarding this matter. The advice of the pharmacist should be sought with regard to selfadministration of controlled medication, as the current practice may not be safe as no risk assessments are in place and no clear procedures documented. St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 13 Everyone has a lockable cupboard in their room for their medication. A storage cupboard has been purchased for controlled medication and this needs to be installed following the recent guidelines provided by the Royal Pharmaceutical Society. A requirement has been made regarding this matter. People spoken with said that staff treat them with respect and provide care in the way that they prefer; one person said she is “treated with consideration and respect”. Staff were observed to be supporting people in a quiet, sensitive and caring manner during the day. St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are few activities arranged so that people can choose a lifestyle experience that matches their expectations. People are supported to maintain contact with their relatives and friends. People are supported to make some choices in their daily lives. People are provided with a wholesome and balanced diet of home cooked food. EVIDENCE: People choose to live at St Anne’s because of the religious foundation of the home. There is a chapel available for daily worship and a priest visits the home regularly. There are two communal lounges that also provide dining facilities. The manager and staff said that most people prefer to stay in their rooms during the day or take a walk in the gardens in good weather. There are no organised activities and no member of staff dedicated to arranging activities. There was recently some dance entertainment in the home and some people were taken out in a minibus for an outing. Two people attend a day centre and some people go out with relatives from time to time. People spoken with said they like spending time in their rooms however some said they might be St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 15 interested in some musical entertainment or quizzes. An activities programme should be developed based on people’s interests and wishes to provide some mental stimulation for people who wish to take part. People are supported to keep in touch with their family and friends. One person said her visitors had been made very welcome and a tray of tea and homemade cakes had been provided for her guests. Visiting times in the home are between 8am and 8pm. People are supported to make some choices in their daily lives including when to get up and what time they wish to take breakfast. A balanced and nutritious diet is provided. Food is home cooked to a high standard. One person said the food is ‘lovely’ and another person said it is easy to digest. There were complaints about the standard of food at weekends and this has now been addressed and people are much happier about the new arrangements. There is a choice of menu and the manager is planning to display a daily menu card on the notice board in an attractive format. People’s likes and allergies are noted on care plans and special diets are catered for. Nutritional assessments would be carried out if there were a concern about someone’s health and everyone has their weight checked each month; these records were seen on case files. Some people choose to take their meals in their rooms and others now sit at dining room tables that have been provided in the first floor lounge; this makes mealtimes more social occasions. St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People can be confident that their concerns and complaints will be listened to and acted upon. The systems regarding safeguarding vulnerable adults to not fully protect people in the home. EVIDENCE: There is a complaints policy and a system for recording and investigating complaints. People said they know how to make a complaint and feel they would be listened to and taken seriously. Two complaints had been recorded and investigated appropriately. The complaints policy should be updated to include the name of the new manager and the new contact details for the Commission. There is a copy of the West Sussex multi disciplinary policy and procedure for safeguarding vulnerable adults. Staff were clear about the need to protect people in the home however it was not clear that all staff have attended updated training on adult abuse and safeguarding vulnerable people. The manager has also not attended any training recently. A requirement as been made regarding this matter. Some staff had begun work before their Criminal Records Bureau (CRB) check had been received; this could have put people at risk of harm and the manager St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 17 agreed that this practice would not continue. A requirement has been made regarding this matter. St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe and well-maintained home that is clean and hygienic. EVIDENCE: The home is well maintained and provides a clean and peaceful place for people to live in. The gardens are also well maintained and are well used in good weather. A company is contracted to keep the building in good order. There is a programme of improvement in place; a bathroom on the first floor is being upgraded with a new assisted bath. The corridors are wide so that people can get around more easily and there are handrails for people who need additional support. People spoken with like their rooms and have brought personal items to the home. St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 19 The manager said in the AQAA that all equipment is serviced as required and necessary safety checks carried out. Not all the windows have restrictors to prevent people falling out and the manager said that this problem is due to be addressed in order to keep people safe. There are adequate laundry and sluice facilities and a system for hygienic disposal has been introduced. There is a dedicated member of staff for laundry duties so that personal laundry is organised efficiently. There is a team of cleaning staff who carry out housekeeping duties and all areas of the home were clean and well cared for. St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s needs are met by the numbers of staff on duty. The recruitment policy and procedure does not fully protect people living in the home. An induction and training programme should be developed to ensure that people have the updated knowledge and skills they need. EVIDENCE: There were sufficient numbers of staff on duty to meet the needs of people living in the home. Call bells were being answered without delay. The manager has introduced a new shift pattern to provide more consistency for residents and staff with a handover meeting between shifts. There are now two carers on waking duty at night to ensure that people’s needs are safely met. The manager said that she sometimes works at weekends to make sure standards remain high and has slept over in the home to carry out spot checks. Three of the fourteen care staff have achieved the National Vocational Qualification (NVQ) at level two or above and two are registered for the award. One member of staff said she has been given more responsibility since she achieved the NVQ award and this has made her feel more valued and has helped her to develop her skills. The manager said she intends to encourage more staff to study for the award. St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 21 There is no recruitment policy in place and the application form is being updated so that it meets current standards. The recruitment records of three staff were seen. The application forms did not provide a great deal of detail about past employment and reasons that people had left their jobs. Some records did not include two written references and two people had started work before a Criminal Records Bureau (CRB) check had been carried out. This was discussed with the manager and she said that this practice would cease to make sure that people are protected. A requirement has been made regarding this matter. There is no formal induction programme in place that meets the Skills for Care guidance. It was not clear that newly appointed staff receive training in moving and handling good practice before they start work to ensure they know how to support people who have mobility problems and also protect their own health. Staff who returned surveys said they had received some training. There is no training programme in place yet and the manager said she would arrange for this to happen to make sure that all staff have the knowledge and skills to do their job well. A requirement has been made with regard to this matter. St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has been operating without a registered manager for more than nine months. There is no clear system to show that people’s views about their care are taken into account. People’s finances are protected. People’s rights and best interests are not fully protected, as not all policies are available or up to date. The health, safety and welfare of service users and staff is not fully protected as mandatory training in health and safety matters is not up to date. EVIDENCE: The home was without a manager for nine months before the present manager was appointed in April. In order to ensure that the business is run efficiently and effectively meets with the regulations then good support must be provided St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 23 to the manager and an application submitted to the Commission for registration. The manager is a registered nurse and has experience of managing a care service; she said that Sister Anastasia has been providing support for her in her new post. There is no formal quality assurance system in place. The manager said that she has held a residents meeting so that people could express their views and she intends to make sure these meetings are held regularly. Questionnaires were sent out in the past but the information was not collated or published to show that any issues raised had been addressed. The manager responded to a complaint about the quality of food at the weekends and took action to change the situation. Sister Anastasia carries out Regulation 26 visits to the home each month and provides a written report of her findings. The manager said that she would be setting up a quality assurance system to make sure that people’s views are sought, listened to and acted upon. There is a system in place for supporting some people to manage their money on a day-to-day basis. The records were clear and the system is audited annually to make sure that people’s finances are protected. The manager indicated in the AQAA that not all the required policies are in place including record keeping, recruitment and employment, racial harassment, bullying, individual planning and review, food hygiene, aggression towards staff and an annual development plan for quality assurance. The home must ensure that all policies are in place and reviewed as required to ensure the efficient and effective running of the home. The policies should be accessible and understood by the manager and staff. A requirement has been made regarding this matter. There are health and safety policies in place and all equipment is serviced as required. It was not clear from the records seen that all staff have undertaken training updates in mandatory health and safety topics including moving and handling, fire safety and infection control. A requirement has been made regarding this matter. Accidents and incidents are reported and monitored to try to minimise risks and keep people safe. St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 2 St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 Reg 14 (1) (a) Regulation Requirement The home must ensure that in the absence of the manager assessments are carried out by someone qualified to do so, before a decision is made about the person moving to the home. Risk assessment should be carried out where a possible risk has been identified for example the safe use of kitchen facilities People who are self medicating should have a risk assessment to ensure that they are able to understand and follow guidance and instructions. Controlled medication should be stored in a facility that meets the current guidance. All staff including the manager should attend updated training in safeguarding adults so that they are able to fully protect people and understand the reporting procedures. No care staff should begin work until two written references and an enhanced Criminal Records Bureau (CRB) or POVAfirst check have been received. DS0000014728.V367697.R01.S.doc Timescale for action 31/08/08 2 OP7 Reg 13 (4) (b) 31/08/08 3 OP9 Reg 13 (2) 31/08/08 4 5 OP9 Reg 13 (2) OP18 Reg 13 (6) 31/08/08 31/08/08 6 OP29 Reg 19 (1) (b) (i) 31/08/08 St Anne`s Convent Version 5.2 Page 26 7 OP37 8 OP38 An induction and training programme that includes Reg 18 (c) mandatory topics, moving and (i) handling, food hygiene and fire safety, must be developed to ensure that staff have updated knowledge and skills. Policies and procedures must be Reg 12 reviewed and updated with (1) (a) changing legislation and good practice advice from the Department of Health. Policies should be available and understood by the manager and staff including guidance on: record keeping, recruitment and employment, racial harassment, bullying, individual planning and review, food hygiene and an annual development plan for quality assurance. 30/09/08 31/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Anne`s Convent DS0000014728.V367697.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 St Anne`s Convent DS0000014728.V367697.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. 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!