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Inspection on 09/05/07 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 9th May 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.

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. People who use the service 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 people 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 embarked on a major refurbishment programme of the bedrooms in the home, to date six rooms have been refurbished and work is due to start on another six rooms in the future. The registered provider has replaced old beds with new electric profile beds that are more suitable for people who need nursing care. The registered person has developed and introduced 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. The deputy matron has reviewed and improved the care planning system in the home.

What the care home could do better:

The registered person needs to continue the development and introduction of a formal quality assurance system to monitor and measure the delivery of services. To ensure that people are fully protected and safe the registered manager needs to develop the current regular formal supervision sessions with staff members. The registered person should ensure that catering staff are familiar with and complete appropriately the food safety management system monitoring forms. The registered person needs to continue the development of person centred care plans including a detailed advanced end of life care plan.

CARE HOMES FOR OLDER PEOPLE St Benedict`s Nursing & Residential Home St Benedict Street Glastonbury Somerset BA6 9NB Lead Inspector Stephen Humphreys Unannounced Inspection 9th May 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 Benedict`s Nursing & Residential Home DS0000003287.V335964.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 Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 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 stbenedictsnursinghome@hotmail.com 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.V335964.R01.S.doc Version 5.2 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 6th June 2006 Brief Description of the Service: St Benedicts Care Home provides nursing to older persons over the age of 65 yrs. It has been developed from a large domestic dwelling house with a purpose built extension. It is within easy walking distance from the town centre of Glastonbury, 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 area to the rear. 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. Experienced nursing and care staff deliver the care. The accommodation is maintained and experienced staff provide a full catering and domestic service. The current fees are from £487 to £535 per week St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced. This was the homes second key inspection under the Inspecting for Better Lives methodology. The administrator Mr P.White and proprietor, Mr D.White were in the home at the time of the site visit. The registered manager was not available at this inspection. The inspector had an opportunity to give feedback and have discussions about the home with the providers on the day of the inspection. 33 people were living at the home and one person was attending for day care on the day of the site visit. Comments received from the people in the home included: ‘I find the matron and deputy matron very professional and the standard of nursing care is excellent’ People spoken to during the inspection confirmed that staff are kind and respectful. The people all said that they were happy at the home and that they felt well cared for. The inspector spent time speaking with people, 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 his plans for improving the home in the near future. What the service 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. People who use the service 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 people who need palliative care and use the Gold Standard Framework model for assessing and planning the care needed. St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The registered person needs to continue the development and introduction of a formal quality assurance system to monitor and measure the delivery of services. To ensure that people are fully protected and safe the registered manager needs to develop the current regular formal supervision sessions with staff members. The registered person should ensure that catering staff are familiar with and complete appropriately the food safety management system monitoring forms. The registered person needs to continue the development of person centred care plans including a detailed advanced end of life care plan. St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 7 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 Benedict`s Nursing & Residential Home DS0000003287.V335964.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 Benedict`s Nursing & Residential Home DS0000003287.V335964.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): Quality in this outcome area is good 3, Relatives and persons using the service are provided with information on the home to enable them to make an informed choice. People have their care needs identified and are encouraged to visit the home before making a decision to come in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The is no change to the statement of purpose and service user guide. The inspector saw both documents displayed in the home at this visit. The matron or her deputy visit and carry out a needs based assessment on all prospective people before they are accepted into the home. The matron St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 10 discusses the needs based assessment with her staff before agreeing to admit the prospective person. The matron and deputy are experienced and skilled at carrying out needs based assessments. The model used is based on the activities of daily living model of care. Admissions to the home only take place when the matron and staff are confident they can meet the person’s needs. People spoken to said they felt their needs were met in the home. Relatives and persons spoken to said the matron provides good information and support when the person enters the home. Relatives spoken to confirmed that the matron had visited to do an assessment of the resident whilst they were in hospital. St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. 7,8,9,10 People are involved in the development of their care plan. People are treated with respect and dignity at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the matron has begun to involve people in the development of their care plans. Each person has a detailed care plan . The inspector reviewed three care plans in detail and six others were read. There was evidence to show that people using the service had been involved in the development of the plan. St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 12 People 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 people who needs palliative / terminal care. Two care plans using the Gold Standard framework were reviewed . 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 reviewed in detail were those of people with complex care needs such as diabetes and wound care. The care plans have improved since the last inspection. Each care plan reviewed provided clear actions for the identified care need. The shortfall in the care planning cycle was that no evaluation is recorded. The care plan has a reviewed date but no record to state whether the actions are meeting the desired outcome. This was explained to the nurse in charge and to the registered person during the feedback session. The registered person is encouraged to improve the care plan process by including a recorded evaluation on the desired outcomes. The care plans developed using the Gold Standard Framework were detailed and included the actions staff should take when the person is reaching an end of life stage. People and relative spoken to during the inspection said they felt their care needs were met fully. Survey results recorded that the people were happy with the care they received. People have access to health care professionals who visit the home. GP’s visit regularly when required. People 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. People confirmed during discussions with the inspector that they were treated with respect and dignity. People 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 people who need palliative care. St Benedict`s Nursing & Residential Home DS0000003287.V335964.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): Quality in this outcome area is adequate. 12,13,14,15 People are able to enjoy a lifestyle in the home that is fairly flexible and accommodating. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An activities co-ordinator is employed in the home however they were not on duty on the day of the visit. The activities are mainly from 2pm until 5pm each afternoon. No activities are planned for the mornings. The inspector was told that two extra staff are put on in the afternoon if an activity has been arranged, such as an outing. During this visit no activities were observed to take place. People were watching television in the main lounge, sleeping and others were observed to be in their rooms reading and doing jig-saw puzzle. St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 14 People 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 people out and recreational equipment is available in the home including television, a small selection of novels and board games. Daily newspapers and magazines were available and being read by people. The planned programme of activities includes group activities such as trips out shopping. The survey carried out by the registered provider showed that some people would like trips to the sea-side. A regular bingo session is held with prizes that include a pampering day. This is a day when the winner can chose what type of pampering they like. 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. One person who is mainly self –caring had an electric kettle that enables them to make a hot drink as they choose. The inspector observed lunch on the day of the inspection. People said the food is generally very good. Two people said they did not like the first choice however they were always offered an alternative. St Benedict`s Nursing & Residential Home DS0000003287.V335964.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): Quality in this outcome area is adequate. 16,18 People in the home are protected from the risk of harm through robust policies and training. People can be assured that any concerns will be taken seriously and investigated using the homes complaints procedure. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes complaints procedure can be found displayed near the main entrance and is included in the statement of purpose and service user guide. The procedure is robust and includes set timescales for which investigations will be carried out. People spoken to said they were aware of how to make their concerns known and to whom, however none of the people had any concerns about the home or the delivery of care. The Commission for Social Care Inspection has not received any concerns or complaints about this service since the last key inspection. St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 16 The inspector reviewed the homes complaints log. No complaints had been recorded. All care staff spoken to said they had received training on vulnerable adult issues. The nurse in charge unfortunately has not. All care staff were aware of how to take action if an incident of abuse occurred. Although the nurse in charge has not had any training in the last twelve months she was aware of what to do if an incident occurred. The registered person should ensure that all staff receive up to date training on vulnerable adult issues. St Benedict`s Nursing & Residential Home DS0000003287.V335964.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): Quality in this outcome area is adequate 19,26 This judgement has been made using available evidence including a visit to this service. People can be assured the service is providing a homely environment. EVIDENCE: Since the last inspection the registered provider has continued with the programme of refurbishment and to improve the décor, fixtures and fittings. The refurbishment programme is timely and will take up to twelve months to complete. New furniture such as commodes, bedside cabinets and wardrobes have been installed in six rooms to date. There is no lockable drawer or facility in the refurbished rooms. The registered provider is planning to install a lock onto the bedside cabinet draw to enable the person to keep valuables safe. St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 18 The registered provider is also encouraged to consider installing a facility should any future person wish to self administer their medication. The refurbishment programme includes up grading the bedrooms en-suite facilities. The hairdressing facility in the home is in need of upgrading to provide people with an environment that can be friendly and comfortable. Several new variable height profile beds more suited to people needing nursing care have been obtained to replace the old fixed height beds. In one bedroom the inspector found bed rails that were not fitted properly and were considered to be a risk to the persons safety. The safety issue was brought to the attention of Mr P.White for action. On the day of the inspection the inspector found the home to be clean and homely. Many of the bedrooms have been personalised with peoples own furniture and ornaments along with pot plants and other personal items. The home has adequate domestic staff to keep the home clean. People said they were comfortable and the home is clean and warm. Lighting is adequate in corridors. The flowing hot water temperature was tested and found to be above 50C from one bath tap outlet. The hot water temperature records showed that the hot water flowing from this tap 43C. The registered provider was informed of the discrepancy and took action. There are two areas in the home that may pose a risk to people. The risks arise due to uncovered radiators in the ground floor corridors. If these radiators were in use the surface temperature would pose a risk to any frail person should they touch the radiator. The inspector was informed that the radiators are permanently turned off to reduce the risk of injury. The problem arises because the corridor is not wide enough for a wheelchair user to get past safely to the rooms if the radiators were covered. The registered person will be required to produce an improvement plan on this area to ensure that during the cold weather months the ambient air temperature in the area is maintained at 70F. It may be effective to ensure that wheelchair users do not accommodate the rooms beyond these radiators. The infection control procedure is robust however there was evidence found during the tour of the home that indicated that the procedure is not always followed completely by all staff. St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 19 The inspector observed bar soap and a nailbrush in communal bathrooms. This was fed back to the nurse in charge during the inspection. St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate 27,28,29,30 This judgement has been made using available evidence including a visit to this service. People who use the service can be assured there are adequate numbers of experienced and skilled nursing and care staff in the home. EVIDENCE: 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 people in the home. The inspector was informed that two extra carers come on duty in the afternoon if an activity is arranged. Staff spoken to 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. 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 provided a wide range of training and development opportunities for them including NVQ training. St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 21 Statutory training such as food hygiene, fire training, manual handling and infection control practices are recorded on the staffs individual training file. 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. During conversations with people who use the service the inspector was informed that sometimes no-one is available to assist them and they have to wait. St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate . This judgement has been made using available evidence including a visit to this service. 33,36,37,38 The registered manager has the experience and skill to run the care home. The registered manager leads and supports a strong person focused staff group. EVIDENCE: The registered person is continually working towards making the home open and transparent. The inspector observed care staff going about their tasks during the visit. Many of the people using this service are very frail with reduced mobility. The home has adequate equipment to ensure pressure relief and hoists to move people safely. All the equipment is maintained at required intervals. St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 23 The registered manager has recently reviewed and updated the policies and procedures. The clinical procedures were up to date with current good practice thinking. Staff were observed to use hoists correctly and other safe practices. Regulation Inspector Justine Button viewed eleven staff files during a visit to the home on The 13th June 2007. The files confirmed that the staff receive regular supervision. The current supervision however needs to be developed further. A number of the supervision records did not allow the staff member, document their comments nor did the supervision record document issues such as future training needs or wishes. This was discussed with the senior staff member on duty during this visit who agreed to review the current supervision arrangements. The registered person carries out satisfaction surveys annually and initiates any improvements as a result of the surveys. A formal quality assurance system needs to be developed which includes the finding from the satisfaction surveys. A quality assurance system should include the strengths and weakness of the home and areas that the home intends to develop over a set time scale. This was discussed with the senior staff at the home who agreed to research quality assurance systems over the next few months with a view to implementing one in the near future. During the tour of the home an inspection of the kitchen was included. The registered provider has 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 was informed by catering staff that the registered person does not require them to complete cleaning records. As a matter of good practice catering staff should complete cleaning records daily to provide evidence of the procedure being carried out. Other statutory records were checked and found to be complete and up to date. St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 3 3 St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 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 OP19 Regulation 13 4(a) Requirement The registered person shall ensure that— all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety: this refers to radiators in the ground floor corridors and the badly fitted bed rails. (a) Timescale for action 30/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP26 OP33 Good Practice Recommendations The registered manager should ensure there is a record of the evaluated outcomes in each care plan. The registered manager should ensure staff follow the infection control procedure at all times. The registered person shall establish and maintain system for evaluating the quality of the services provided at the DS0000003287.V335964.R01.S.doc Version 5.2 Page 26 St Benedict`s Nursing & Residential Home care home. This refers to the introduction of a quality assurance system that includes quality audits and risk assessments. 4 OP36 The registered manager should continue to develop the current supervision system to ensure that all staff have input into the supervision meetings. St Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Benedict`s Nursing & Residential Home DS0000003287.V335964.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!