Inspection on 11/08/05 for St Aubyns

This inspection was carried out on 11th August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Aubyns 11/07/07

St Aubyns 30/05/06

St Aubyns 28/02/06

St Aubyns 04/03/05

St Aubyns 29/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE St Aubyns 35 Priestlands Park Road Sidcup Kent DA14 7HJ Lead Inspector Maria Kinson Unannounced 11 August 2005 09:40 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. St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Aubyns Address 35 Priestlands Park Road Sidcup Kent DA15 7HJ 020 8300 4285 020 8300 4285 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 Dilipkumar Tanna Mr Kirtikumar Tanna Mrs Jean Woodcock Care Home with Nursing 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: An additional five (5) day care places for people falling into the above Service User Categories. Date of last inspection 04 March 2005 Brief Description of the Service: St Aubyn’s Nursing Home is situated in a residential area of Sidcup, near to a mainline rail station, bus routes and Sidcup town centre. The home was first registered in 1988. The building was extended in 1995 and is registered with the Commission for Social Care Inspection to provide nursing care for thirtynine older people. There are nineteen single bedrooms and ten shared bedrooms in the home. Twenty-two of the bedrooms have en-suite facilities. Service users have shared use of the dining room and two lounges. There is a garden at the back of the property and limited parking at the front of the home. St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 11.08.05 between 09.40am and 18.45pm. The inspector undertook a partial tour of the home and spent time talking with residents, a visitor, staff and the management team. A variety of documents were examined including care, medication, complaint, accident, staff training and health and safety records. Comment cards were left for visitors and were sent to health and social care professionals that were in regular contact with the home. Eight questionnaires were returned to the commission. Since the last statutory inspection on 04.03.05 the commission has undertaken two additional visits to the home to investigate two anonymous complaints and to monitor staffing levels. The first complaint related to the supervision of residents on the first floor of the home. The complaint was not substantiated but two recommendations were made. The second complaint was about the supervision of residents in the lounge and was upheld in part. The Registered Person was required to make proper provision for the supervision of residents during the handover period. This requirement was assessed during this inspection and was met. A brief summary of the inspector’s findings during these visits can be obtained upon request. What the service does well: This home has a stable team of staff, many of whom have worked in the home for several years. Staff had a good understanding of their role and responsibilities and had established good relationships with many of the residents. The food prepared in the home was good. Residents were satisfied with the quality and choice of food provided. Good systems were in place to ensure that frail residents were helped with fluids throughout the day and assisted at mealtimes. The building was well maintained and all areas were kept clean, tidy and free from unpleasant odours. Good attention was paid to infection control issues. Staff had established good working relationships with other professionals and managed health care issues effectively. Comments received from other health care professionals indicated that staff were “extremely organised and helpful” and that “senior nurses were clinically competent and communicate well”. St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 6 Staff addressed residents in a respectful manner and took action to ensure that resident’s privacy and dignity was maintained when undertaking personal care. Relatives were satisfied with the overall care provided in the home and said that staff were approachable and helpful. One relative told the inspector that since her mother had moved into the home she had been able to visit less frequently as she was confident that her mother was safe and well cared for. What has improved since the last inspection? What they could do better: The homes Statement of Purpose and Service Users Guide did not provide adequate information for residents. These documents must be reviewed and updated. Overall care documentation was mostly good but staff should ensure that resident’s social needs are assessed and incorporated into their care plan. The current system for managing medicines did not provide sufficient detail to complete a full audit trail. It is essential that the manager can assess and account for all medicines received in the home. Access to vocational training for care staff had improved but nursing staff had received little training during the past year. All staff must receive adequate training and training records must be kept up to date. St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 7 The Registered Person must ensure that adequate records are maintained and kept in the home. This includes contracts, terms and conditions of occupancy and reports about unannounced visits made to the home. Access to the main part of the home was secure but some concerns were identified about the entrance into the garden. 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. St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 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 St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 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 and 3. Standard 6 does not apply to this home. The home did not provide sufficient written information for prospective residents. Residents must be given adequate information to make an informed choice. The information obtained during the pre- admission assessment assists staff to meet resident’s needs on admission to the home. EVIDENCE: The home has a Statement of Purpose and Service Users Guide. The previous requirement to include additional information in the Statement of Purpose about the organisational structure of the care home, the range of needs the home is intended to meet, the number of rooms in the care home and the number and experience of staff working at the care home had not been addressed. See requirement 1 and recommendation 1. The Service Users Guide must also be reviewed and updated to include all of the information listed in The Care Homes Regulations. See requirement 2. St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 10 The inspector was not able to assess whether residents had a written contract and terms and conditions of occupancy, as these documents were not kept in the home. See requirement 3. Staff assessed resident’s needs prior to admission and obtained additional information from the funding authority where possible. Assessments were undertaken by senior staff and were recorded on a form that covered all of the areas of need listed in the National Minimum Standards for Older People. Staff wrote to prospective residents to confirm whether the home was able to meet their needs. St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 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 and 10 Resident’s health and welfare needs were met by staff and appropriate action was taken to maintain resident’s privacy and dignity. Some of the systems for managing medication in the home did not provide adequate information to ensure residents safety. EVIDENCE: Staff undertook a brief assessment of residents needs on admission to the home and developed a plan of care for each resident. Overall the information recorded in care plans was good, but there was little evidence that resident’s social needs were considered. See standard 12 and recommendation 3. Access to health care services was good and staff worked in partnership with other professionals. Records indicted that staff took prompt action to investigate medical issues and sought advice from the General Practitioner or other professionals where necessary. The comments received from health care professionals that visit the home indicated that staff communicated effectively and had a good understanding of residents needs. Records of receipt and disposal of medication were good but did not provide sufficient detail to allow a full audit trail to be undertaken. Information on the St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 12 medication chart was hand transcribed by one member of staff. The nurse administering medication signed the medication sheet once to indicate that all of the medication prescribed for that period had been given. The Royal Pharmaceutical Society guidance recommends that hand written medicine charts are checked and agreed by a second person and states that all signatures must be linked to a specific medicine. One box of medication was not prescribed on the medication administration chart. The register and storage of controlled drugs was satisfactory and the temperature of the drugs refrigerator was monitored closely. The home does not use homely remedies. There were a variety of policies and procedures to guide staff that were responsible for managing medication. The procedure for disposing of medication indicated that small amounts of medication could be disposed of in the sluice. Staff were aware that this was not an acceptable method of disposing of medication. It is recommended that all medication procedures are reviewed and updated if necessary. The manager was aware of the new arrangements for the disposal of medication. See requirement 4 and recommendation 4. Staff ensured that residents were appropriately dressed and had personal items such spectacles and reading materials within reach. Doors were kept closed during personal care and at other times if residents requested this. St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 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 and 15 Resident’s social needs were not being met at the time of this inspection but significant work was in progress to address this issue. A good selection of food was provided in the home to meet resident’s nutritional needs and tastes. EVIDENCE: There was little evidence of regular activities taking place in the home. Since the last inspection the manager and staff had begun to prepare an activities programme and had attempted to recruit a designated Activities Coordinator. Work was in progress to consider the type of activities that would be suitable for residents and to purchase equipment. The Registered Manager said that the activities post would be re-advertised and the programme introduced in August 2005. See recommendation 3. Three relatives responded to the questionnaire sent out by the commission and feedback was obtained from one visitor who was present at the time of the inspection. Relatives were satisfied with the visiting arrangements and said they were made welcome by staff. All of the relatives were satisfied with the care provided in the home and indicated that they were kept informed about important matters. All of the residents spoken with were satisfied with the quality and choice of food provided in the home. The food provided on the day of the inspection St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 14 was well balanced and looked appetising. The only exception to this was the pureed food, which was served in a bowl. Some of the residents were given alternative dishes because they did not like the food listed on the menu or because they required a specific diet. Staff provided assistance to cut food up and prompting if necessary. A number of residents required soft food and thickened fluids and were totally dependent on staff for meeting their nutritional needs. Arrangements were in place to ensure that these residents were given the assistance that they required. St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a comprehensive complaints and adult protection procedure in place for responding to complaints or allegations of abuse. EVIDENCE: The homes complaints procedure was displayed in the reception area. The procedure includes a timescale for responding to concerns and contact details for the commission. There was no record of any complaints being received in the home since last inspection. Since the last statutory inspection on 04.03.05 the commission has undertaken two additional visits to the home to investigate two anonymous complaints about the supervision of residents and to assess staffing levels. One complaint was upheld in part. The Registered Person was required to make proper provision for the supervision of residents during the handover period. This requirement was assessed during this inspection and had been met. The home has an Adult Protection and Whistle Blowing procedure. Staff were aware that they should report allegations of abuse or misconduct to senior staff immediately but were not always clear about the homes Whistle Blowing procedure. The Registered Manager should ensure that this topic is discussed with staff. St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The home was maintained to a satisfactory standard providing residents with a clean and comfortable place to live. EVIDENCE: The building was maintained to a satisfactory standard. Since the last inspection additional hoists, fans, bed linen and towels had been purchased. All parts of the home were clean, tidy and odour free. Plans were in place to redecorate all of the bedrooms in 2005 and replace the lawn in the garden with an alternative covering. An inspector from Bexley Environmental Health Department inspected the main kitchen in August 2005. The kitchen was found to be clean and well maintained. Four requirements were made relating to the storage of food, assessment of potential hazards, refrigerator door seal and flooring. Written information provided by the manager indicated that action was being taken to address all of these issues. St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 17 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 and 30 The home has a stable team of caring staff who work hard to meet resident’s health and welfare needs. Access to training had improved but further work should be undertaken to ensure that all staff receive adequate training on an ongoing basis. EVIDENCE: Copies of the off duty roster for the period prior to and following the date of the inspection were examined. Action had been taken to comply with the staffing notice by increasing the number of trained nurses on a late shift. Agency staff were employed on a temporary basis when the home did not have an adequate number of permanent nurses to work certain shifts. Work had also been undertaken to attain accreditation with Manchester University to provide assessment and training for nurses from overseas who wish to register and work in the UK. This should provide the home with additional staff for future use. Plans were in place to increase the number of care staff during the morning shift. This will provide additional time for trained staff to undertake supervision, training and management tasks. Eight staff had recently commenced a national vocational qualification in care. One staff member already has this qualification and three staff were working as carers but have a nursing qualification obtained outside the UK. This home is actively working towards meeting the Department of Health target for 50 of care staff to achieve a vocational qualification in care by 2005. St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 18 Access to training for some care staff had improved but nursing staff and care staff that were not registered on a vocational course, were not receiving adequate training. The inspector examined two staff files. There was no written evidence that the staff members had undertaken any training since the last inspection. Discussions with the manager did indicate that some staff had attended short training sessions about nail clipping and a peg feeding update. Other sessions were planned. The manager had started to adapt the homes induction-training programme to comply with National Training Organisation standards. A draft copy of the induction programme was shown to the inspector. The manager was also working towards setting up a foundation-training programme for staff to follow during the first six months of their employment. Further work must be undertaken to ensure that training records are kept up to date and induction and foundation training programmes are introduced. See recommendation 5. St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 19 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 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) 33, 35, 37 and 38 This home was well organised and managed overall but there was little written evidence of work being undertaken to obtain feedback from residents or to assess the homes performance. Action was taken to provide a safe environment for residents and staff but some concerns were identified about security. This issue must be addressed promptly to ensure that residents are protected. EVIDENCE: Recommendations made during previous inspections about implementing a formal quality assurance system in the home had not been addressed. A fire safety audit was undertaken regularly but no other audits or quality assurance work had taken place. See recommendation 6. This home does not usually store personal money for residents but an exception was made for one of the residents who does not have any close family or friends. The money was stored in an envelope in a locked cupboard. St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 20 A record was maintained of all money deposited for safekeeping or returned to the resident and a staff signature. It is recommended that the resident is also asked to sign to confirm that she has received money or another staff member provides a witness signature. See recommendation 7. The previous requirement to ensure that adequate records and reports were kept in the home had not been addressed. The inspector requested copies of the reports for the unannounced visits that took place in June and July 2005. Copies of the reports were not kept in the home and the Registered Provider said that it was not possible to get copies of the reports faxed through to the home. It was agreed that copies of the reports requested would be faxed to the commission on 13.08.05. This information has not been received. See requirement 3 and 5. A selection of health and safety records were examined. The records seen indicated that equipment and utilities were serviced at regular intervals and repairs were undertaken where necessary. Fire safety records were mostly satisfactory but the combined fire alarm test and fire drill record did not include the names and numbers of staff attending the drill or how quickly staff had responded to the alarm being activated. Fire safety training for staff was being arranged at the time of this inspection. The last fire safety training session provided for staff took place in April 2004. See recommendation 5 and 8. This inspection took place on a hot day. Staff had opened some of the fire exit doors to allow air to circulate throughout the building. The gates at either side of the building were unsecured allowing free access to the ground floor corridor. The Manager said that the side gates had never been locked in the past. Staff must assess potential risks to residents and implement strategies to reduce risks where possible. See requirement 6. St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 x x N/A 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 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x 3 x 2 2 St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 22 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 1 Regulation 4 Requirement The Registered Person must amend the Statement of Purpose to include the following information: the organisational structure of the care home, the range of needs the care home is intended to meet, the number of rooms in the care home and the number and experience of staff working at the care home. A copy of the revised Statement of Purpose must be forwarded to the Commission within 28 days of any changes being made. (See also recommendation 1) (Previously agreed timescales (01.01.05 and 01.06.05) were not met) The Registered Person must amend the Service User Guide to include the following information: the address and telephone number for the commission, a summary of the complaints procedure and information about access to inspection reports. A copy of the revised Service User Guide must be forwarded to the Commission within 28 days of any changes being made. (See also G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Timescale for action 01.11.05 2. 1 5 01.12.05 St Aubyns Version 1.40 Page 23 recommendation 2) 3. 2 & 37 17 Schedule 3 Schedule 4 (8) The Registered Person must keep a copy of all correspondence relating to the service user in the care home. This includes contracts and terms and conditions of occupancy. (Previous timescale of 01.12.04 and 01.06.05 were not met) The Registered Person must ensure that all medicines that are prescribed for residents are recorded on the medication administration chart, that staff signatures are linked to the administration of a specific medicine and that records of medicines enable staff to undertake a full audit trail and account for all medicines. The Registered Person must supply the Commission and the Registered Manager with a copy of the report that he is required to prepare under regulation 26 of The Care Homes Regulations 2001. (Previous timescale of 01.06.05 was not met) The Registered Person must assess whether the current arrangements for access into the home present any risks to residents. Action must be taken to reduce risks where possible. A copy of the risk assessment must be forwarded to the lead inspector by 01.10.05. 01.12.05 4. 9 13 01.11.05 5. 37 26 01.11.05 6. 38 13 01.10.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. St Aubyns Refer to Standard Good Practice Recommendations G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 24 1. 2. 1 1 3. 7 & 12 4. 9 5. 30 6. 33 7. 8. 35 38 The Registered Person should amend the Statement of Purpose to include information about how the home meets the following standards 20.4, 21.4, 22.2, 22.5 and 23.10 The Registered Person should amend the Service User Guide to include the following information: a description of the communal space, the number of places provided and any special needs catered for, the qualifications and experience of the Registered Manager, Provider and staff, access to inspection reports, residents views of the home and how the home meets standards 20.4, 21.4, 22.2, 22.5 and 23.10. The Registered Provider should ensure that residents social needs are assessed and met. A record should be maintained of activities provided in the home and community. The Registered Provider should ensure that medicine charts that are handwritten are agreed and signed by two members of staff and medication policies and procedures are reviewed and updated. The Registered Person should ensure that staff receive a minimum of three paid training and development days per year and receive induction and foundation training to NTO standards. The Registered Person should monitor the quality of care provided in the home, on a continuous basis, using a recognised tool. An internal audit should be carried at least once a year. The Registered Person should ensure that adequate records are maintained of money kept for safekeeping for residents. The Registered Person should ensure that fire drill records include staff response times. St Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection River House 1 Maidstone Road Sidcup, Kent DA14 5RH National Enquiry Line: 0845 015 0120 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 Aubyns G51 G01 S6771 St Aubyns V220633 11.08.05 Stage 4.doc Version 1.40 Page 26 - 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. 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