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Inspection on 24/01/06 for St Benedict`s Nursing & Residential Home

Also see our care home review for St Benedict`s Nursing & Residential Home for more information

This inspection was carried out on 24th January 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

On the day of the inspection there were several residents who were being nursed in bed. All the residents spoken too said they were happy with the care they received. The residents observed to be up and sitting in the lounge appeared to be well dressed. Staff were observed to interact with residents in a polite manner.

What has improved since the last inspection?

The overall judgement of the inspectors was that no noticeable improvements have taken place. In discussion with the homeowner, he indicated that a major refurbishment of the home will take place in 2006 and all outstanding work will be done.

What the care home could do better:

The care delivery in the home is good and appreciated by the residents. Introducing a person centered care approach could move the overall quality of care forward. This was discussed with Mrs Carey and her deputy during the feedback session. Training and professional development for all nursing and care staff, on this issue, would benefit residents through improved health and social care practices. As stated in the last report the furnishings and fittings are tired and a planned refurbishment and replacement programme is needed for the home. Care plans do not contain regular assessment or reviews and do not detail the care required in sufficient detail for staff to follow. There is no evidence that the care plan was drawn up with the residents or their representative`s involvement. The majority of residents do not have the opportunity to engage in stimulating and meaningful social or recreational activity except for the television and reading magazines and papers. Not all staff have received training in food hygiene or first aid. Staff do not receive formal supervision to help them in their practice and development.

CARE HOMES FOR OLDER PEOPLE St Benedict`s Nursing & Residential Home St Benedict Street Glastonbury Somerset BA6 9NB Lead Inspector Justine Button Unannounced Inspection 24th January 2006 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 Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 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 Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Benedict`s Nursing & Residential Home Address St Benedict Street Glastonbury Somerset BA6 9NB 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) 01458 833275 01458 833402 Mr David Edwin Wills White Mr Leslie Wills White Mrs Pamela Margot Carey Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Elderly persons of either sex, not less than 60 years, who require general nursing care Up to 9 beds for personal care. Date of last inspection 16th August 2005 Brief Description of the Service: St Benedicts Care Home is formed from an adapted house with a purpose built extension. It is within easy walking distance from the town centre, although up a slight hill. Accommodation is on two floors, with a four-person lift. There is a level patio area approached from the lounge and there is a garden laid mainly to lawn. There are 26 single rooms and 6 double rooms. 29 rooms have en-suite facilities. The home provides nursing care for up to 30 people and personal care for up to 9 older people. St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and carried out by two inspectors. The Lead inspector was Justine Button accompanied by Stephen Humphreys. The inspection was from 09.45am until 16.45pm. Mrs Pam Carey, the registered manager was in the Home and available through out the day. The proprietor, Mr R.White visited the home for a short time during the day. The inspectors would like to thank Mrs Carey and her deputy for their co-operation and help during the inspection. Feedback at the end of the inspection was given to Mrs Carey and her deputy. 34 people were living at the home and one service user was attending for day care on the day of this inspection. All of the residents living at the service and relatives spoken to were satisfied with the care and service they receive at the home. The inspectors concluded that the registered persons are providing good care however the furnishing and fittings are looking tired and dated. The registered person needs to introduce a planned replacement programme of furnishings and fittings throughout the Home. People spoken to confirmed that staff are kind and respectful and inspectors observed staff interacting in a kindly manner with all service users. The inspector’s objective on this inspection visit was to seek views on the quality of the service from as many service users as possible and to speak to staff. A tour of the premises was made, care in the home observed and the statutory records were reviewed. What the service does well: What has improved since the last inspection? St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 6 The overall judgement of the inspectors was that no noticeable improvements have taken place. In discussion with the homeowner, he indicated that a major refurbishment of the home will take place in 2006 and all outstanding work will be done. What they could do better: 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 Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 7 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 Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 8 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 the following standard(s): 1, 2, 3, 4 & 5. Standard 6 –Intermediate Care is not available at St Benedict’s Nursing Home Prospective residents and families are provided with information about St Benedict’s to help them make a choice about moving into the home. Each resident has a signed service agreement with the home. A needs based assessment is carried out prior to a person moving in to the home. Resident’s care needs appeared to be met to their satisfaction. EVIDENCE: The statement of purpose can be found in the entrance hall. The document was reviewed by one of the inspectors. Parts of the document need to be updated, these include the complaints procedure, the home’s insurance details St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 9 and the CSCI details. A copy of the service users guide is available in all the bedrooms. One of the residents said that she had not read the guide but she knew what it was about. The service user guide was not available in a suitable format so that it can be read or heard by all residents with differing disabilities. Each resident has a service contract. In discussion with Mr Philip White it was felt that the contract needs reviewing in line with the Office of Fair Trading guidance and standard 3, as not all the terms and conditions were included to meet this standard. Prior to moving into the home a member of the senior staff team go to meet the prospective individual. During this visit an assessment of needs is conducted. This assessment ensures that the home can meet the needs of the person. The assessment is documented and forms the basis of the initial care plan. A number of the initial assessments were viewed. One resident said she felt at home, and that St Benedict’s was nice. Other residents said that staff attend fairly quickly when they press the call bell. Relatives spoken to confirmed that they were able to visit the home when looking to choose a service. St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Each resident has a plan of care that identifies the health care needs as determined by the Registered Nurse. The health needs of the residents who live in St Benedict’s are met in part. Medication is administered safely. Residents said the staff respect them when carrying out personal care. Resident’s wishes at the time of their death are recorded. EVIDENCE: All people who live at the service have a care plan which details their health and personal needs. There is no evidence of any social care needs being identified or associated activities delivered. St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 11 Five of the plans were viewed in detail. These demonstrated that assessments had been completed but not evaluated or dated. The free nursing care (Registered Nursing Care Contribution) and social worker assessments were included in the care plan. The assessments are then used in the development of the individuals care plan. The plans were written in clear English. None of the plans for any of the residents showed evidence that the individual had been involved in the development or review of their plans. The care needs identified, in the main did not have achievable outcomes, this is indicated by the rigid practices. As a matter of good practice a person centered approach to care needs to be introduced. The care plans reviewed did not address the assessed needs of the residents as follows Nutritional assessments were not completed in detail and the plan lacked detail for example “to provide a nutritionally balanced diet” is used frequently. Catheter care plan did not contain detail required for the individual just recorded ‘ encourage fluids’ Care plans lacked information about meeting social care needs including the provision of stimulation where people have significant sensory or cognitive disabilities. Details of wound care did not reflect the progress of the wound or identify the type of pressure relieving equipment needed to meet the tissue viability needs. The care planning system needs to be reviewed to ensure it contains all the necessary health, personal and social care needs with achievable outcomes. There are a number of specialist beds and mattresses available. These are used in the prevention of pressure sores and help staff when supporting people who are nursed in bed. The amount of pressure relieving equipment needs to be reviewed with regard to pressure relief cushions. The medicine administration, storage, ordering and disposal procedure met the standard. As a matter of good practice a copy of the FP10 certificate should be kept in the home. People and relatives who were spoken to during the inspection all stated that the staff treated them with dignity and respect. Staff were observed knocking on bedroom doors prior to entering. Staff were also observed treating and talking to people in a kindly manner. St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 12, 13, 14 & 15. A limited range of social activity is available in the Home these need to be developed. Residents have contact with family and friends as they wish. Meals are satisfactory however there is very little choice on offer. EVIDENCE: No activities were observed on the day of the inspection. The matron said that there was no dedicated activities co-ordinator; activities are dependant on the care staff having time to do it. Residents were observed to be watching television and two residents were reading a magazine. At least two residents in the home had sensory disabilities including being registered blind and deaf. There was no evidence of any stimulatory aids to assist these residents with any social care. The inspector observed lunch on the day of the inspection. Egg, bacon, beans and chips were served. Residents requiring a soft diet were served separately. None of the residents complained that the meals were not adequate but from St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 13 observation the main meal did not look nutritious or balanced to meet the needs of the resident. No evidence was found to suggest that the residents are involved in the development of the menu for the home. To ensure a balanced and nutritious diet is provided the chef should seek advice from a dietician from the local primary care trust. St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 16. The home has a complaints procedure displayed near the front entrance. EVIDENCE: Residents were asked if they had any concerns and whom they would take their concerns to if they had any. All responded that they would speak to matron about their concern. The complaint procedure included in the statement of purpose and service user guide still does not have the correct Commission for Social Care Inspection address. There have been two complaints since the last inspection both are currently being looked into by Commission for Social Care Inspection. St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26. Residents live in a clean, warm environment that is looking tired in parts. Infection control practices appear to be lacking in parts. EVIDENCE: The home was clean and tidy on the day of inspection. The home is safe and secure. A tour of the building found items of furniture that was damaged, two devan beds had broken legs, an armchair with torn fabric, a bedroom with a cracked window and fittings in need of replacement. People are able to personalise their rooms with their own possessions. In one room was a stained bedrail bumper and a stained carpet. Most of these items were identified at the last inspection. The registered person has not attempted to make better any damaged or worn fixtures or fittings which appear to place the residents at risk of harm or injury. St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 16 There are 4 communal bathrooms with assisted baths and 6 en-suite bathrooms, which also have adapted baths. There is one shower room. There are toilets sufficient in number. The communal bathrooms are in need of refurbishment. There is a garden, laid mainly to lawn and this is accessible for wheelchair users. The manager stated that a number of additional commodes have been bought but there is still not sufficient for one per resident. The management needs to ensure that there are adequate commodes for the number of residents who may need to use a commode especially during the night. The heating and lighting were appropriate on the day of inspection. Radiators have been covered in bedrooms and bathrooms but not in corridors or lounges. The radiators in the corridor by the main front door and in the corridors were very hot to touch. The registered person has not taken any action to ensure the safety of the residents or other persons who may be in the home. There is a chance that residents or staff may burn themselves on the unprotected radiators. The water temperature is thermostatically controlled to the baths but not the sinks. The signs on the sinks need to be large enough for persons with poor sight to read. The temperature of the flowing hot water to baths and sinks has been recorded as being between 50 and 60C. This is way above the recommended 43°C by the Health & safety executive and is placing the residents at risk of scalding injuries. Suitable hand washing measures are in place. Grab rails are in place and hoists attached to baths. The evidence is that the registered person must take appropriate action to ensure the residents are living in a safe environment. The lock on the ground floor sluice was damaged which effectively results in the inability to lock the sluice room. A container of bleach was found stored in the sluice. The housekeeper confirmed that she used the bleach as part of her cleaning substances. The sluices are the old Belfast sink type and do not meet the care standard regulations or are suitable to meet the nursing homes control of infection standard. St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Staff numbers on duty are adequate to meet the personal and health care needs of the residents but not to meet the social care needs. Recruitment procedure is satisfactory to protect the residents. Staff do not receive all the training they require to carryout the work they perform. EVIDENCE: The matron provided copies of the staff rota at the time. These showed that on average eight staff were on duty in the morning and five in the afternoon and evening. Agency staff are being used currently to cover sickness and annual leave. The manager stated that she tries to ensure that the same agency staff are used in order to offer continuity and consistency. Seven staff files were reviewed. Included in the files were the training records. Fire and manual handling records were separate. A range of training had been completed by care staff from food hygiene to NVQ level 2. In discussion with the matron and her deputy it is apparent that the nursing staff would benefit from further training on clinical issues especially dementia care. St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 18 Only one staff file included a certificate to show that the carer had received infection control training. The deputy manager said that approximately 40 of staff need to under go training including update training on food hygiene and first aid. There was no evidence of a planned training matrix to ensure that all staff receive the statutory training during the year. St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 36, 37 & 38. The registered manager has developed a close working relationship with her team over many years in the home. A friendly atmosphere is evident in the home. The health and safety arrangements are not satisfactory. EVIDENCE: Observation and conversation with staff shows that they worked well together as a team. All staff and residents know the registered manager. The residents and relatives said that they were happy with staff some sighting specific members of staff in particular for the care they deliver. St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 20 No evidence of any formal quality audits being carried out was found. The registered person is apparently no longer at the home on a daily basis. The owner’s son has now taken over the day-to-day administration duties. The registered person will be required to visit the home at least monthly and interview with their consent residents, relatives and staff to find out their views on the home. He must inspect the premises and any records or complaints. The registered person must also send a written report to CSCI as per the requirements of regulation 26 Care Homes Regulations 2001. Policies and procedures were checked and found to be in need of review and updating. Last review was 2003. The deputy manager confirmed that no staff supervision takes place formally. The staff would benefit from formal supervision to support them in addressing the practice issues especially the infection control procedure. A regular system of supervision is required to be set up. The following records were reviewed during the inspection: Fire logbook – records completed showed alarm, emergency lights and drills carried out as required. Hot water temperatures – this has been recorded at between 50° – 60°C Clinical Waste certificate – was out of date. Risk assessments in general have been completed but are in need of reviewing. Accident book was completed satisfactorily. Electric and gas testing certificates were in date. St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 2 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 1 1 1 1 X 2 3 2 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 X X 2 2 2 St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 22 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 OP8 Regulation 12 (1) (a) Requirement That the number and type of pressure relieving mattresses is reviewed. That equipment is provided in line with the assessed needs of the service user. That the number of adjustable beds and commodes are reviewed and equipment is provided in line with the assessed needs of the service user group. THIS WAS A REQUIREMENT AT THE LAST INSPECTION 20/10/05 The Registered person must provide social and recreational activities, to ensure there is adequate stimulation and opportunities for outings. THIS WAS A REQUIREMENT AT THE LAST INSPECTION 30/10/05 The Registered Person must ensure that the premises are kept in a good state of repair internally through a planned repair or replacement programme. A copy of the plan to be forwarded too Commission for Social Care Inspection office. DS0000003287.V280255.R01.S.doc Timescale for action 30/03/06 2. OP12 16 (2) (m) (n) 30/03/06 3. OP20 23 (2) (b) 30/03/06 St Benedict`s Nursing & Residential Home Version 5.1 Page 23 4 OP1 6 (a) 5 6 OP1 OP2 6 (b) 5 (1) (b) 7 OP4 12 (1) 8 OP7 15 (1) 9 OP8 14 (2) 17 (1) (a) 16 (2) (i) 10 OP15 11 12 OP19 OP33 13 (4) (c) 24 (1) (2) 13 OP33 10 (1) 12 10 (a) The registered Person must revise the statement of purpose and service user guide too ensure they are up to date. The registered person must send a revised copy to Commission for Social Care Inspection office. The registered person must provide each resident with terms and conditions to include: Room occupied Rights and obligations of the service user. The registered person must ensure the needs of residents with sensory disabilities are met using current good practice and clinical guidance. The registered manager must ensure that the resident or their representative is involved in the development of the care plan, agreed and signed by them. The registered manager must ensure that all residents have regular nutritional assessment and a record of action taken. The registered person must provide a varied menu of suitable meals including a range of choices to meet the resident’s wishes. The ground floor sluice must be kept locked to ensure the safety of the residents. The registered person must introduce a quality assurance system that includes quality audits. The registered person must send a copy of the quality report to Commission for Social Care Inspection. The registered manager must review and up date as necessary all policies and procedures in the home taking into account NICE and SCIE clinical guidance procedures. DS0000003287.V280255.R01.S.doc 30/03/06 30/03/06 10/04/06 10/04/06 10/04/06 10/04/06 10/04/06 30/03/06 30/06/06 30/06/06 St Benedict`s Nursing & Residential Home Version 5.1 Page 24 14 15 OP33 OP36 26 (1) (3) (4) (5) 18 (20 16 OP38 13 (4)(c) 17 OP38 13 (3) The registered person must carry out and make a report of his visit with regards to this regulation. The registered manager must introduce a system to ensure that all staff receive formal supervision. The registered person must ensure the flowing hot water from bath, shower and wash hand basin outlets does not exceed 43°C by installing thermostatic regulator valves. 7A planned programme of installation is required. The registered manager must ensure that bleach is stored in a secure locked store. 28/02/06 30/03/06 30/03/06 28/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. 3. 4 Refer to Standard OP9 OP19 OP26 OP38 Good Practice Recommendations A copy of the FP 10 certificate should be kept in the home for each resident. As a matter of good practice the registered person should develop a programme of routine maintenance and renewal for the fabric and decoration of the premises. The registered person should install a sluice disinfector for cleaning commode pans as part of the infection control procedure in the home. Risk assessments developed with regards to the environment should be reviewed and up dated. St Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Benedict`s Nursing & Residential Home DS0000003287.V280255.R01.S.doc Version 5.1 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. 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!