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Inspection on 06/06/06 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 6th June 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

St Benedict`s nursing home has a well established and competent management team. The matron provides strong leadership with support from the provider. The staff team are all motivated and willing to learn and develop new skills. Residents and relatives are provided with information on the homes services in normal and large print versions of the statement of purpose and service user guide. Nursing staff are experienced in caring for residents who need palliative care and use the Gold Standard Framework model for assessing and planning the care needed.

What has improved since the last inspection?

The registered provider has updated the statement of purpose to include recent changes and to enable prospective residents to make an informed choice. The registered provider has embarked on a major refurbishment programme of the bedrooms in the home. Bed linen and curtains have been replaced through out the home. Bedroom furnishings have been replaced with new furniture and carpets. The registered person has developed and will be introducing a planned staff training programme that will support the personal development for all staff groups. Activities and social care has been improved, with the appointment of an activities person. Recreational activities are mainly home based but include trips out for cream teas weather permitting.

What the care home could do better:

The registered person needs to set up and implement a formal quality assurance system to monitor and measure the delivery of services. Communication between some overseas staff and residents could be improved through training and addressing the diversity and cultural issues within the home. Lack of storage facilities in the home is a problem however the registered person needs to address and stop the current practice of parking the mobile hoists in areas that cause obstructions, such as walkways, and compromising the safety of the residents and visitors to the home.The registered manager must develop a management culture based around risk assessment. To ensure that residents are fully protected and safe the registered manager needs to set up regular supervision sessions with staff members. A proactive approach to care planning should include evidence of resident or relative involvement. Care plans should include detailed instructions to staff on what to do for persons experiencing hypo or hyperglycaemic attacks or if residents need oxygen to be administered. Care plans could be more detailed in relation to identifying specific social care and communicating aids to persons with sensory problems. To promote a person centred approach to meeting social care needs a planned programme of activities that is developed with residents should be introduced. The homes cook/s should be provided with opportunities to attend training courses above basic food hygiene level. The registered person should ensure that catering staff are familiar with and complete appropriately the food safety management system monitoring forms.

CARE HOMES FOR OLDER PEOPLE St Benedict`s Nursing & Residential Home St Benedict Street Glastonbury Somerset BA6 9NB Lead Inspector Stephen Humphreys Key Unannounced Inspection 6th June 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.V290850.R02.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.V290850.R02.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 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.V290850.R02.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 24th January 2006 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.V290850.R02.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 over two days. This was the homes first key inspection under the Inspecting for Better Lives methodology. Mrs Pam Carey, the registered manager was in the Home and available through out the day. The administrator Mr P.White and proprietor, Mr D.White were in the home at various times during the two days. The inspector had an opportunity to give feedback and have discussions about the home with the providers on the second day of the inspection. 35 people were living at the home and one service user was attending for day care at the time of the inspection. The inspector sent out satisfaction surveys to ten residents at St Benedicts prior to the inspection. Comment cards were also sent to the main GP’s who provide medical care to the residents. Comments received from the surveys included: ‘I find the matron and deputy matron very professional and the standard of nursing care is excellent’. Residents spoken to during the inspection confirmed that staff are kind and respectful. The residents all said that they were happy at the home and that they felt well cared for. Two residents commented about the difficulties in communication with some of the overseas staff. Since the last inspection the Commission for Social Care Inspection has received two letters of concern about St Benedict’s Nursing Home. Inspectors from the Commission for Social Care Inspection investigated both concerns. The provider was also involved in the investigation. The issues identified in one of the concerns were investigated as part of this inspection. The outcome of the investigation was that none of the issues where upheld. The complainant has been informed of the outcome. The inspector spent time speaking with residents, staff, relatives and carried out a tour of the premises. Time was spent observing carers carrying out their duties in the home and all the statutory records were reviewed. The proprietor discussed with the inspector his plans for moving the home forward and to improve the service delivery. What the service does well: St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 Page 6 St Benedict’s nursing home has a well established and competent management team. The matron provides strong leadership with support from the provider. The staff team are all motivated and willing to learn and develop new skills. Residents and relatives are provided with information on the homes services in normal and large print versions of the statement of purpose and service user guide. Nursing staff are experienced in caring for residents who need palliative care and use the Gold Standard Framework model for assessing and planning the care needed. What has improved since the last inspection? What they could do better: The registered person needs to set up and implement a formal quality assurance system to monitor and measure the delivery of services. Communication between some overseas staff and residents could be improved through training and addressing the diversity and cultural issues within the home. Lack of storage facilities in the home is a problem however the registered person needs to address and stop the current practice of parking the mobile hoists in areas that cause obstructions, such as walkways, and compromising the safety of the residents and visitors to the home. St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 Page 7 The registered manager must develop a management culture based around risk assessment. To ensure that residents are fully protected and safe the registered manager needs to set up regular supervision sessions with staff members. A proactive approach to care planning should include evidence of resident or relative involvement. Care plans should include detailed instructions to staff on what to do for persons experiencing hypo or hyperglycaemic attacks or if residents need oxygen to be administered. Care plans could be more detailed in relation to identifying specific social care and communicating aids to persons with sensory problems. To promote a person centred approach to meeting social care needs a planned programme of activities that is developed with residents should be introduced. The homes cook/s should be provided with opportunities to attend training courses above basic food hygiene level. The registered person should ensure that catering staff are familiar with and complete appropriately the food safety management system monitoring forms. 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.V290850.R02.S.doc Version 5.1 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 Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 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 the following standard(s): 1,3,4,5 The quality in this outcome group is good. Relatives and residents are provided with information on the home to enable them to make an informed choice. Residents have their care needs identified and are encouraged to visit the home before making a decision to come in. EVIDENCE: The statement of purpose and service user guide developed for St Benedict’s nursing home was reviewed pre-inspection visit. The information contained in the documents meets the national minimum standards. A copy of the service user guide and statement of purpose can be found available at the main entrance next to the visitor’s book including a large print version. A copy of the service user guide was seen in resident’s bedrooms. Two residents spoken to could remember receiving and reading the service user guide. The matron or her deputy visit and carry out a needs based assessment on all prospective residents before they are accepted into the home. Relatives spoken to confirmed that the matron had visited to do an assessment of the resident whilst they were in hospital. All the residents spoken too said they St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 Page 10 were in hospital prior to coming to St Benedict’s. All said their relatives chose the home for them following a meeting with matron and looking around the home. St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 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 the following standard(s): 7,8,9,10,11 The quality of this outcome group is adequate. Residents are not involved in the development of their care plan. Residents are treated with respect and dignity at all times. EVIDENCE: Residents have a detailed care plan, but the practice of involving them or their relative in the development or review is not routine. Residents funded by social services had a care plan and copies of the six monthly reviews were included in the care plan record. The matron has introduced the Gold Standard Framework care plan for residents who needs palliative / terminal care. Two care plans using the Gold Standard framework were reviewed and the residents included in the case tracking exercise. Six other care plans were reviewed in detail. The care plans are developed using the activities of daily living model of care and include risk assessments on falls, tissue viability, continence, and mobility. The care plans included in the case tracking exercise included residents with diabetes and other complex needs. The care plans lacked clear instructions for St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 Page 12 carers on actions to take in the event of hypo / hyperglycaemic attacks or if the residents should need oxygen therapy. The care plans developed using the Gold Standard Framework were detailed and included the actions staff should take when the resident is reaching an end of life stage. Residents and relative spoken too during the inspection said they felt their care needs were met fully. The resident survey results recorded that nine out of ten were happy with the care they received. To make the care plan a working record the resident needs to be involved in its development. Residents have access to health care professionals who visit the home. GP’s visit regularly when required. Residents confirmed they received visits from chiropodist and the optician. Nurses are responsible for all medicines and for administration, storage, recording and disposal. All medicines including the controlled drugs were checked. A self-medication policy includes a resident assessment and consent. One resident was identified to administer topical creams themselves. Residents confirmed during discussions with the inspector that they were treated with respect and dignity. Residents said “you get well looked after here”. Policies and procedures on palliative care are on display and nursing staff have experience and skills in caring for residents who need palliative care. Residents care plans who were case tracked included appropriate pain management plans. The medicine prescription sheets confirmed appropriate analgesic medicine had been prescribed. An issue of poor health care practice was investigated specifically during this inspection. No evidence of poor personal or health care practice was found. Evidence was collected by speaking to residents’ and observing carers carrying out planned interventions. During a tour of the home including visiting bedrooms no evidence of urine odour or dirty linen was found. The concerns were not upheld. St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 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 the following standard(s): 12,13,14,15 The quality in this outcome group is adequate. Residents are able to enjoy a lifestyle in the home that is fairly flexible and accommodating. EVIDENCE: Since the last inspection an activities co-ordinator has been employed. The activities are mainly from 2pm until 5pm each afternoon. The activities coordinator said she had been on a specific course pertaining to activities for people with dementia. Other sessions include group activities such as trips out and one resident said she goes out shopping regularly and gardening. The activities could be improved with more resident involvement in the development of the programme. Residents in wheelchairs would also benefit from raised garden beds to enable them to participate more freely in their like of gardening. There are no restrictions to visiting, relatives were observed to come and go during the inspection. Relatives spoken too said they are made welcome at all times. Residents are able to maintain their independence as much as possible in the home with support and assistance provided by staff. Transport is available to take residents out and recreational equipment is available in the home St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 Page 14 including television, a small selection of novels. Daily newspapers and magazines were available and being read by residents. Residents were observed to be watching television in the lounge and in private. One resident was enjoying doing a large jig-saw puzzle. Two residents had numerous potted plants in their room, which they care for. One resident who is mainly self –caring had an electric kettle that enables her to make a hot drink as they choose. At least two residents in the home had sensory disabilities, one of the residents had hearing problems and one lady had poor eyesight. Case tracking of these residents was carried out during the inspection. The resident with poor eyesight was very frail and receiving palliative care and did not partake in any activities. One resident with hearing loss said she joins in the activities but particularly likes watching the soaps. The resident was equipped with television control and a daily paper with the current weeks television programmes. The inspector observed lunch on the day of the inspection. Residents said the food is generally very good. Two residents said they did not like the first choice however they were always offered an alternative. The cook said she was aware of the residents’ likes and dislikes and tries to provide dishes for each taste. St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 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 the following standard(s): 16,17,18 The quality in this outcome group is good. Residents in the home are protected from the risk of harm. Residents can be assured that any concerns will be taken seriously and investigated using the homes complaints procedure. EVIDENCE: The Commission for Social Care Inspection has received two complaints since the last inspection. The investigation into one of the complaints was carried out as part of this inspection. An inspector from the Commission for Social Care Inspection investigated a recent complaint with the assistance of the registered manager. The outcome of this complaint was an action for the registered manager to ensure that all staff communications was improved. The issues investigated during this inspection pertained to personal care and staffing. The issues were not upheld. The homes complaints procedure can be found displayed near the main entrance and is included in the statement of purpose and service user guide. It is available in large print in the statement of purpose. The procedure appears robust and includes set timescales for which investigations will be carried out. The procedure does state clearly that concerns can be made directly to the Commission for Social Care Inspection before going to the registered manager or registered provider. Residents and relatives spoken to said they were aware of how to make their concerns known and to whom, however none of the residents or relatives had any concerns about the home or the delivery of care. St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 Page 16 One resident said they had a grumble about the food but this was sorted out another resident said “ if I have any complaints I sort them out, I think the overseas staff should have better command of the English language”. The pre-inspection survey results recorded that all knew how to make concerns known and had any concerns about the service delivery in the home. At the time of this inspection no local or national elections were taking place however residents said that they have had opportunities to vote in political elections. The registered manager arranges for residents to receive a postal vote at election times. All staff spoken to said they had received training on vulnerable adult issues and that they were aware of how to take action if an incident of abuse occurred. St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The quality in this outcome group is adequate. Residents can be assured the home is maintained and is clean and warm. EVIDENCE: Since the last inspection the registered provider has improved the internal environment of the home. A programme of room refurbishment is under way and will take up to twelve months to complete. New furniture such as commodes, bedside cabinets and wardrobes have been installed. Curtains and bedding have been replaced as well as some room carpets. The refurbishment programme includes up grading the bedrooms en-suite facilities. The hairdressing facility in the home is in need of upgrading to provide residents with an environment that can be friendly and comfortable. Several new variable height profile beds that are more suited to people needing nursing care have been obtained to replace the old fixed height beds. St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 Page 18 On the day of the inspection the inspector found the home to be clean and homely. Many of the bedrooms have been personalised by the resident. Residents own furniture and ornaments were noted along with pot plants and other personal items. The home has adequate domestic staff to keep the home clean. No malodours were noticed and the Commission for Social Care Inspection is not aware of any infection outbreaks since the last inspection. St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality in this outcome group is adequate. Residents can be assured that there is always adequate numbers of experienced and skilled nursing and care staff in the home. EVIDENCE: The inspector reviewed the duty rotas for the week of the inspection and two previous weeks. The number and skill mix of care staff appeared to be of a sufficient level to meet the nursing and personal care needs of the residents in the home. No comments were received from residents about the level of staffing or the service delivery. Two residents commented that they had trouble communicating with some of the overseas staff at times. This issue was discussed with the registered manager at the end of the inspection. The registered manager has started to take action to improve this concern. The inspector had discussions with two overseas staff during the inspection. Both staff were clear about their roles and responsibilities and were able to relate appropriate actions should the fire alarm sound or if there was an incident involving a vulnerable adult. Difficulty did appear in there understanding in relation to being asked to contact an emergency service via telephone. St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 Page 20 Generally carers would not be asked to contact an emergency service by telephone however to ensure quality service delivery staff in all staff groups should be able to communicate clearly if requested to use the telephone. The home has a robust recruitment procedure that is followed by the registered manager when employing staff. All the necessary checks on the employee are recorded and filed safely. All the staff members talked to during the inspection confirmed that the registered person provide a wide range of training and development opportunities for them including NVQ training, statutory training such as food hygiene, fire training, manual handling and infection control practices. Domestic and catering staff also have training on health & safety and COSHH. Nursing staff receive adequate opportunities to enable them to meet their individual PREPP (professional development) requirements. Specialist training received by care and nursing staff has included palliative care, continence care, stroke awareness and first aid. The activities coordinator and some carers have attended a training course about activities for people with dementia. St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,38 The quality in this outcome group is adequate. The management team is well established and run the home in the best interests of the residents. Lack of attention to quality procedures may not ensure residents are fully protected. EVIDENCE: Observation and conversation with staff shows that they worked well together as a team. All staff and residents know the registered manager and said that she always has time to listen or chat with them. The residents and relatives said that they were happy with staff some sighting specific members of staff in particular for the care they deliver. During a discussion with the registered manager she acknowledged that she audits all accident records and identifies risks to residents and the appropriate action to take. The inspector reviewed completed accident records to confirm this, however there is no formal quality assurance system set up that includes formal audit and risk assessment records. The registered manager has not St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 Page 22 introduced formal staff supervision sessions, as was required at the last inspection. The registered manager does send out resident satisfaction surveys annually and initiates any improvements as a result of the surveys. The staff team is close and appears well supported by the registered manager and her deputy, but a formal quality assurance system including supervision, monitoring and risk assessment must be introduced to show how the registered persons are recognising and protecting residents through safe working practices. The registered manager said that staff appraisals are carried out annually and that the quality audit for Somerset County Council is completed annually. Staff and records confirmed these were correct. No risk assessments on health & safety issues, such as, the parking of the mobile hoists are recorded. The practice of parking the hoists in an area on the first floor that causes the walk-way to be obstructed and on the ground floor in such a way that it prevents a fire door from automatic closure must be stopped. The registered provider confirmed that storage of equipment was a problem in the home. During the tour of the home an inspection of the kitchen was included. The registered provider has recently introduced a new food safety management system, developed by the Food Standards Agency, and incorporates the HACCP (Hazard and Critical Control Point) requirement. The new system requires the catering staff to complete various records to show how they are maintaining food safety in the home. Unfortunately the cook is not completing the records adequately to ensure a safe food system is in place. The inspector also found the fly killer needed cleaning and the fly screen on the window was damaged. Both of these items should be addressed as part of the safe food management system. Kitchen cleaning records need to be completed fully and the menus should be reviewed so that they clearly record the choices available to residents. Hot water outlet temperature records were checked, temperatures were recorded at between 44C and 47C which is higher than the recommended 43C. The registered person must ensure the temperature of the flowing hot water is not more than 43C and appropriate risk assessment is recorded, until all hot water outlets are fitted with thermostatic regulator valves. St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 Page 23 Other statutory records were checked and found to be complete and up to date. Policies and procedures were checked and found to be in need of review and updating. St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 X X X X X X 3 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 3 X 2 X X 1 X 2 St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 Page 25 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 OP30 Regulation 18(1)(a) (C)(i) Requirement The registered manager must ensure all staff members are competent in using the telephone to call an emergency service. The registered manager must introduce a quality assurance system that includes quality audits and risk assessments. This requirement was not met from last 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. The registered manager must introduce a system to ensure that all staff receive formal supervision. This requirement is not met from last inspection. The registered provider must ensure the flowing hot water from bath, shower and wash hand basin outlets does not DS0000003287.V290850.R02.S.doc Timescale for action 30/07/06 2 OP33 24 (1) (2) 30/07/06 3. OP33 10 (1) 12 10 (a) 30/07/06 4. OP36 18 (2) 31/07/06 5. OP38 13 (4)(c) 31/07/06 St Benedict`s Nursing & Residential Home Version 5.1 Page 26 exceed 43°C by installing thermostatic regulator valves. St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 Page 27 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. Refer to Standard OP7 Good Practice Recommendations The registered manager should ensure that care plans include specific instructions to nursing and care staff on what actions to take to administer oxygen or measures to counter a hypo / hyperglycaemia. The registered manager should ensure the care plan contains evidence to show that residents are involved in the development of the plan. The registered manager should ensure residents are involved in the development of the activities programme. The registered manager should review the complaints procedure so that readers are clear who they can make complaints to at any time. 2. OP7 3. 4. OP12 OP16 St Benedict`s Nursing & Residential Home DS0000003287.V290850.R02.S.doc Version 5.1 Page 28 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.V290850.R02.S.doc Version 5.1 Page 29 - 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!