Inspection on 18/04/07 for St Bathens

This inspection was carried out on 18th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Bathens 25/02/09

St Bathens 02/11/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE St Bathens 88 Newbridge Hill Bath Bath & N E Somerset BA1 3QA Lead Inspector Grace Agu Unannounced Inspection 18th April 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Bathens DS0000067143.V334669.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 Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Bathens Address 88 Newbridge Hill Bath Bath & N E Somerset BA1 3QA 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) 01225 319293 M & J Care Homes Ltd Mrs Juliet Denise Grier Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd November 2006 Brief Description of the Service: St.Bathens is a care home owned by M&J Care Homes Ltd and provides accommodation for up to 16 older people. There was a change of ownership of the home in May 2006; however, the new owners have retained the former owner and registered manager to act as the registered manager. This has provided valuable continuity for the existing residents and staff. The home is situated in the Newbridge area of Bath with bus access to the city centre it is also conveniently located close to the local Health Centre where most of the residents are registered. St.Bathens is a converted older property and the home is two properties made into one. It is on two floors with some of the rooms only being accessed by stairs; however, there is a lift to the first floor. There is a large lounge area at the front of the house, a dining room and conservatory with access to attractive gardens and patio area. St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken over eight and a half hours to review the care practice to ensure that it is in line with legislation and that best practice is followed at the Home. The inspection also followed up the action the home had taken to ensure that the last inspection requirements were met. The Home was found warm, well lit, clean and free from unpleasant odours. The residents were found relaxed and looked well cared for in their homely environment. The Manager was unavailable on the morning of the inspection however staff met on duty professionally assisted and cooperated with the inspection process. Whilst touring the building staff were noted interacting with the residents in a dignified, friendly and sensitive manner. Information about care of the residents and the services provided at the home were obtained through review of records, including policies and procedures, care files, staff training, staff recruitment and speaking to residents and a small number of staff What the service does well: Prospective residents are assessed before admission to the Home and the Home ensures that a Service Users Guide is given to them to enable them to make an informed choice about moving to the Home. Residents and relatives are informed on admission about the one-month trial period to enable the home to determine if they are able to meet the needs of the resident and to give the resident the opportunity to make a decision whether to stay. The home provides a warm, clean and comfortable environment for the residents and ensures that adequate aids and equipment are in place to promote independence, mobility and to assist staff with meeting the needs of residents. From discussion with staff and residents and including comments from the residents and relatives’ surveys, it was apparent that the home provides personalised care for the residents and ensures that their dignity and privacy is upheld. St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 6 One relative’s comment on ‘what the home does well’ include “caring for clients’ needs, Listening to relatives observation/requests and reacting helpfully where possible. Maintaining a secure and peaceful atmosphere. Keeping relatives informed as to the many aspects of the clients health settling in and quality of life”. What has improved since the last inspection? What they could do better: Whilst reviewing medication, some minor medicine chart discrepancies were noted. Some medication was noted with instruction “as directed” this could potentially lead to drug error. The home must obtain clear instructions from the dispensing pharmacist to prevent this from happening. To ensure that residents’ medication is safe and the home is made less vulnerable, the medicine trolley must be secured on the wall. The medicine trolley must not be stored in the shower room to ensure that the bathing facility for the residents is not compromised. Whilst touring the building it was noted that the shower was used to store the medicine trolley. The senior carer met on the day confirmed that the shower room was used for permanent storage for the trolley and that only one resident used it. The home must provide an alternative storage facility for the medicine trolley to ensure that residents have access to the shower room at all times. The home must ensure that no individual is employed at the home without appropriate recruitment procedures to ensure safety of the residents. Details of this can be found in the report under Standard 18. At the last inspection a requirement was made about training staff on the Protection of Vulnerable Adult. from abuse it was disappointing to note that this had not taken place despite repeated requirements. The home is reminded that failure to comply with this requirement could lead to enforcement action. St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 7 It was noted that home has limited stimulating activities for the residents, the home must review the activities programme with the residents to ensure that activities are tailored to meet individual capabilities and choices. 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 Bathens DS0000067143.V334669.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 Bathens DS0000067143.V334669.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home undertakes full and comprehensive assessments of prospective residents to ensure ability to meet their needs. EVIDENCE: The home has an admission policy that evidenced that they would assess the residents before admission. Records reviewed evidenced that pre-admission assessments were undertaken before two individuals were recently admitted to the home St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9.10 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents are looked after well in respect of their health and personal care needs and care plans are in place to support staff in meeting the needs of the residents. Generally medication administration procedures are satisfactory. However minor adjustments are needed to ensure safety of the residents. The home needs to review medication administration procedures to ensure safety of the residents EVIDENCE: Records evidenced that the residents’ physical, emotional and social needs were assessed and care plans were in place describing how the needs were being met. St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 11 There was also evidence of assessed potential risks to the residents and plans were in place to minimise the risks. One staff member spoken with whilst reviewing the care plans stated the home has purchased a new care planning system and that the Key workers are reviewing the care needs with individual residents to ensure that the needs are adequately met, the newly completed care plans were comprehensive and personalised. Residents spoken with stated that staff respected their privacy and treated them with respect. One resident stated, “ I like it here, staff are respectful, I get up and retire when I like usually they answer when I ring the bell.” The inspector noted care staff knocking at the residents’ doors and waiting for an answer before going in to attend to the residents in their bedrooms. Two staff members spoken with confirmed that they are able to meet the needs of the residents through reviewing the care plans, regular hand over and discussion with the residents. The two residents care files viewed evidenced that the General Practitioner and other health professionals were involved in the management of the residents care. One comment card received from a health professional states, “ homely atmosphere, regarded highly locally as providing excellent care, clients appear well dresses, and content”. The procedure for the administration, storage and disposal of medication was reviewed and showed that a local pharmacy provides medication using a monthly monitored dosage system. A check of the blister packs indicated that medication had been administered as recorded. All medication seen was stored securely. Medicines trolleys are used to transport medication around the home. A policy is available to enable residents to look after their own medicines. All medication is ordered and received by staff. One resident looks after her own medication. The medicines administration record sheet indicates any medicines that are self-administered. The pharmacy supplies printed medicines administration record sheets each month. However some records seen indicate that minor adjustments need to be made to ensure safety of the residents. St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 12 The home must ensure that the medicine trolley had the means to secure it to the wall to protect residents’ medication and minimise the homes vulnerability to theft. Medication (insulin, hydrocortisone creams and eye drops) must not be stored in the food fridge. Three medications for individual residents were labelled ‘as directed’ and must have clear instructions to prevent drug error. Staff are aware of the home’s policy and procedure for dying and death and this was confirmed through a comment card from a health professional. It states, “ Recent death highlighted good teamwork and cooperation/effective working with district nurses and General Practitioners. All involved in decision making to support family and resident’s wish to die at St Barthens”. St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14.15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are enabled to maintain contact with families, friends and local communities. Choices are provided to residents in respect of meals and mealtimes however; the home has not provided the residents with structured and meaningful activities. EVIDENCE: Discussion with residents and staff showed that the home supports the residents to maintain contact with friends and family in the local community. One resident spoken with stated “my son visited occasionally” and another resident stated that her daughter visited quite regularly. Residents spoken with confirmed that they have a choice of when to get up and retire. One resident stated, “The staff are good, you can’t fault them. However, it was disappointing to note that residents were sitting in the lounges and their rooms with no meaningful activities. Two residents in the conservatory were playing a game of Beetle Drive with an activities person employed to provide activities for the residents once a week. St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 14 The senior carer met on the day stated that an occupational therapist visits every two weeks to do exercises with residents. The residents met in the lounge confirmed this and stated that they look forward to the exercise sessions. Other activities for the week noted on the board in the communal area include 18/04/07 Beetle Drive 19/04/07 Coffee morning. The inspector was informed that an entertainer visits the home monthly to talk to residents about the ‘old times’. At a discussion one carer told the inspector that the manager takes the residents out sometimes, on one occasion the manager invited the residents to their house and entertained them. This is a good gesture. The home must involve the residents to develop a planned varied activities programme they would enjoy individually and as a group that meets their capabilities The home is to ensure that residents with preference to stay in their rooms receive regular personal documented interactions to prevent boredom. The menu was reviewed and it was noted that there was no choice at lunch times to enable the residents to decide what they would wish to eat. The manager stated that the residents are informed by staff in the morning about the meal for lunch and are provided with alternatives if an individual is not happy with the meal. Vegetarian and diabetic meals are also provided on request. The manager stated that the menu would be reviewed in the coming week and that the home intends to display the menu on the notice board in the conservatory where the residents would be able to view and choose the meal that they would like for lunch. This would be reviewed at the next inspection. The kitchen was found clean. A record of fridge and freezer temperatures and food probing were also up to date. However, hazardous medical solutions that are detrimental to peoples’ health must not be stored on the kitchen shelf St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported to exercise their legal rights and are confident that the home will listen to their complaints. Residents are protected through Protection of Vulnerable Adults Policies and Procedures. EVIDENCE: The home has a complaint procedure, which is displayed in the communal area of the building. This document contained information about the Commission for Social Care Inspection to enable the residents to contact the Commission if the were not satisfied with the outcome of their complaint to the organisation. Residents spoken with and evidence from the survey completed by the residents and relatives confirmed that they would contact the manager if the had any complaint or concern. The home has no complaint book however there is a suggestion box situated strategically in the building where the residents can drop in their suggestions or concerns The manager stated that the box is emptied regularly and any concerns are investigated and resolved as soon as possible. The inspector was not shown any recorded complaints. St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 16 The home must ensure that all complaints are recorded, detailing how the complaint was responded to and if the complainant was satisfied with the outcome of the complaint. Responses received from relatives confirmed that they would complain to the Manager, and that they were aware of the complaints procedure. Residents spoken with confirmed that they are enabled to complain and would complain to the Manager if they were not satisfied with any area of the service. Policies and procedures in relation to Protection of Vulnerable Adults from Abuse was noted at the home, and the manager confirmed awareness of the procedure to be followed if an incidence of abuse occurs. Residents spoken with confirmed that they are aware of the voting process and would normally vote by postal system. St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents enjoy a pleasant, safe and homely environment with a good standard of hygiene. However the home compromises resident’s bathing facility by using it as storage for medicine trolley. EVIDENCE: The environment was found comfortable and well suited to the present category of residents. It is able to meet their needs and is accessible to the community facilities The home has spacious and well-decorated lounges and provides a relaxing environment for the residents. The residents were found sitting in the communal areas and appeared relaxed in their homely environment. St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 18 The home was found clean, warm, well lit, beautifully decorated and free from unpleasant odours. Whilst touring the building it was noted that the shower was used to store the medicine trolley. The senior carer met on the day confirmed that the shower room was used for permanent storage for the trolley and that only one resident used it. The home must provide an alternative storage facility for the medicine trolley to ensure that residents have access to the shower room at all times. The clinical waste is correctly disposed of to prevent the spread of infections. There is an infection control policy in place. One resident survey response in terms of cleanliness states, “The home is always very clean and very good cleaner who does lots of things beyond her duty”. Residents spoken with stated that they “felt safe at the home”. The laundry room was noted to be clean and tidy and has suitable equipment to wash and dry the residents’ clothes. St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment policy of the home offers protection to the resident at the home. However the home fails to follow the procedure to ensure that residents are protected. There is adequate numbers of staff that are competent to meet the needs of the residents. EVIDENCE: On the day of inspection, there was an adequate number of staff members on duty to meet the needs of the residents Evidence from the rota showed that there were two carers on duty in the morning, two carers in the afternoon. There were also one waking and one sleep-in carer at night. The senior carer met on duty on the day confirmed that the staffing level was adequate and was maintained on a regular basis. The home also employs a cook, and a cleaner. Review of the training record showed that some staff members have achieved National Vocational Qualification (NVQ) at level 2.and 3. St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 20 Other training attended included medication competency, infection control; fire safety First Aid and food hygiene In relation to health and safety training staff members have attended training updates, However, it was disappointing to note that some staff members have not attended training on the Protection of Vulnerable Adults from Abuse to ensure that resident are adequately protected This is in order to meet the requirement issued at the last inspection. This requirement is repeated. Another requirement was issued to ensure that staff receive this training for the protection of residents. The home is reminded that failure to meet requirements could lead to enforcement action There is a recruitment policy and procedure at the home to ensure that only appropriate, suitable and experienced staff are recruited at the home. Whilst reviewing the recruitment documentation of two newly appointed staff members the inspector noted that one staff member recruited had appropriate recruitment documentation and induction before and after commencement of employment respectively. However, the documentation for one staff member was not satisfactory and did not comply with the home’s recruitment Policy, Procedure and the Regulation. The individual had one reference however it was unclear how the reference was obtained. Furthermore a Criminal Records Bureau (CRB) disclosure was from a different organisation. The home had completed a CRB form however this document had not been sent to the appropriate authority for clearance. The individual had been working at the home for one week, the manager explained that the individual was recruited through a recruitment agency and that the home would ensure that all necessary documentation was obtained and copies forwarded to the Commission. A feedback form was left for the home to confirm the agreement with the home manager. These documents were sent to the Commission before this report was completed. The home must ensure that no individual is employed at the home without appropriate recruitment procedures to ensure safety of the residents. St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33.36.37,38 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The home is well managed, staff are supervised regularly, the home protect the residents through satisfactory health and safety practices EVIDENCE: Mrs Juliet Denise Grier previously owned the home and had been registered manager of the home before it was sold to the present owners in November 2006. The manager continues to manage the home following agreement with the present provider. St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 22 Residents and staff spoken with said they were pleased with this arrangement because it had provided them with continuity and stability. The registered manager has achieved the Registered Managers Award and has attended various training relevant to her role to enable her to provide effective leadership to the home. In relation to health and safety evidence showed that staff have attended fire drills. The Fire safety logbook was well maintained. All health and safety checks were up to date. There is a service record of the lifts, hoists, bath hoists and portable appliance tests (PAT) of all electrical appliances. Accidents to residents were recorded. It was agreed that accidents need to be reviewed following falls and where appropriate care plans and risk assessments reviewed to ensure that the individual is adequately protected and to prevent further occurrences. Various Policies and procedures were in place, relevant, updated. Residents’ information was appropriately stored and locked away. Residents, staff and relatives made positive comments about the manager and expressed satisfaction with the overall services and management of the home. One resident stated, “I am happy here, the manager and staff are good”. One relative stated I am satisfied with the care of my relative” Staff supervision records were checked and staff members have received regular supervision to enable them to express areas of concern in relation to residents’ care and to support staff to carry out their responsibilities in providing good care for the residents. Residents’ monies checked evidenced that the record is up to date, the amount stored in the safe corresponded with the balance recorded in the book. One resident informed the inspector that the call bell in the person’s room has not been working properly for some time. The manager confirmed this and stated that the home is looking into installing a new call bell system to replace the existing one in order to solve the problem. Staff are aware of the situation and would ensure that the individual is regularly monitored. The home must ensure this action is speeded up to enable this individual to summon help in emergency situation. St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X 2 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 3 3 X X 3 3 3 3 St Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement “The registered person shall make arrangement for the recording, handling, safe keeping, safe administration and disposal of medicines received at the care home”. (a) Ensure that the medicine trolley is secured to the wall when not in use. All medication from the dispensing pharmacy must have clear instructions (not as directed) instructions to avoid drug error. “The registered person shall having regard to the size of the care home and the number and needs of the resident” develop a planned varied programme of activities to meet the needs and capabilities and wishes of all residents. “The registered person shall having regards to the number and needs of the resident provide suitable storage facility for the medicine trolley. DS0000067143.V334669.R01.S.doc Timescale for action 31/05/07 2. OP12 16 30/06/07 3. OP21 23 (2) (l) 31/05/07 St Bathens Version 5.2 Page 25 4. OP30 18 (1) (i) Ensure all staff completes Adult Protection training. This requirement is repeated “The registered person shall not employ a person to work at the care home unless the person is fit to work at the home” Two satisfactory references must be obtained in regard to a recently employed staff member at the home. Current CRB disclosure must be obtained for the same individual 30/06/07 5. OP29 19 18/05/07 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 Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Bathens DS0000067143.V334669.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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