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Inspection on 03/06/08 for Hallaton Manor

Also see our care home review for Hallaton Manor for more information

This inspection was carried out on 3rd June 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

The home was clean and fresh and well maintained. Staff were observed to interact well with residents and provide a good standard of support and care, and treated residents with respect and dignity. Assessments, health, personal and social care needs were set out in comprehensive plans of individualised care. A wholesome and appealing diet, which residents said was very good, was provided in pleasant surroundings. Meal times appeared relaxed and residents who required assistance were helped in an unobtrusive and supportive manner. The well-tended garden and gymnasium provides residents with alternative activities.

What has improved since the last inspection?

Requirements and recommendations made at the last inspection had been fully met.

What the care home could do better:

Requirements & Recommendations This is what the home must do to improve. Requirements: The Statement of Purpose and Service Users Guide should contain all of the information as stated in Care Homes Regulations 2001, Schedule 1 to ensure that potential residents have the correct, up-to-date information to decide if the home is the right one for them. All staff, including new staff during induction, should be provided with `safeguarding vulnerable adults` training. Recommendations: All contracts should include all of the information as detailed in the Care Homes for Older People, National Minimum Standards, Standard 2, specifically the room/s to be occupied.Residents and/or their relatives/representatives should be involved in and sign care plans to show that they agree with the plan of care whenever possible. The medicines fridge should be checked to ensure that it is running at the correct temperature to ensure medicines that require refrigeration do not deteriorate. Where a resident is restricted from leaving the home unaccompanied the reason why should be documented in the resident`s plan of care and in accordance with the Mental Capacity Act 2005. The carpet, in the room identified to the deputy manger, should be deep cleaned to remove staining or be replaced. Regular supervision & appraisal of all staff should be commenced as soon as possible to support staff and identify their training needs. The food fridge and freezer temperatures should be checked and recorded daily to safeguard the residents from the possibility of food poisoning.

CARE HOMES FOR OLDER PEOPLE St Bernards Cranoe Road Hallaton Market Harborough Leicestershire LE16 8TZ Lead Inspector Mrs Carole Burgess Unannounced Inspection 3rd June 2008 10:00 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 Bernards DS0000001825.V365741.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 Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Bernards Address Cranoe Road Hallaton Market Harborough Leicestershire LE16 8TZ 01858 555271 01858 555332 elainefarrall@aol.com 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) St Bernard’s Hallaton Manor Limited Alison King Care Home 41 Category(ies) of Past or present alcohol dependence (41), registration, with number Dementia - over 65 years of age (41), Learning of places disability (6), Mental disorder, excluding learning disability or dementia (41), Old age, not falling within any other category (41), Physical disability (33) St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following category: Old age, not falling within any other category - Code OP Physical Disability - Code PD : over the age of 40 years Alcohol dependency - Code A:over the age of 40 years Mental disability - Code MD:over the age of 40 years Learning disability - Code LD:over the age of 40 years Dementia - Code DE(E):over the age of 65 years. 2. 3. 4. Nobody falling within the category PD may be admitted to the home when there are 33 persons already accommodated in that category. Nobody falling within the category LD may be admitted to the home when there are 6 persons already accommodated in that category. The maximum number of people who can be accommodated is: 41. Date of last inspection 11th July 2007 Brief Description of the Service: St Bernard’s (now known as Hallaton Manor) is a care home providing personal care and accommodation for up to forty-one older persons, who may have additional care needs including mental disorder, dementia, past or present alcohol dependency and learning disability. The home is a large converted country house, which is situated in beautiful countryside approximately one mile from the village of Hallaton. Accommodation is on two floors that can be accessed via stairs or a passenger lift. The rooms are single occupancy with en suite facilities. There are a variety of sitting rooms and a dining room, with a separate facility for those residents wishing to smoke. St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 5 The home has ample gardens and outside areas that includes a small but wellappointed gymnasium. Minibus transport is available for residents. The Statement of Purpose, Service Users Guide & last Inspection Report are available (these provide information on how the home is organised and what services they provide). The Statement of Purpose and Service Users Guide are provided for any prospective residents and their families. At the time of the inspection the deputy manager said that fees ranged from £695 to £1000 per week, depending if the resident was social service or privately funded, and was dependant on the level of care required. There are extra charges for hairdressing, chiropody, newspapers and any additional care time if residents are accompanied to hospital. St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. ‘We’ as it appears throughout the Inspection Report refers to ‘The Commission for Social Care Inspection.’ The focus of the inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who use the service and their views of the service provided. The site visit was unannounced and took place over six hours. We selected three residents and tracked the care they received through a review of their records, discussion with them (where possible), other people who use the service, the care staff, and observation of care practices. We spoke with staff members regarding training and support. Planning for the inspection included assessing notifications of significant events, complaints about the service and reviewing the home’s service history to date. The Registered Manager was unavailable at the time of inspection but the deputy manager and other staff spoken with were positive and helpful during the inspection. A number of residents spoken with said,“ Staff are very nice, “the food is good” and “the home is always kept clean”, and “I have no complaints” St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: Requirements & Recommendations This is what the home must do to improve. Requirements: The Statement of Purpose and Service Users Guide should contain all of the information as stated in Care Homes Regulations 2001, Schedule 1 to ensure that potential residents have the correct, up-to-date information to decide if the home is the right one for them. All staff, including new staff during induction, should be provided with ‘safeguarding vulnerable adults’ training. Recommendations: All contracts should include all of the information as detailed in the Care Homes for Older People, National Minimum Standards, Standard 2, specifically the room/s to be occupied. St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 8 Residents and/or their relatives/representatives should be involved in and sign care plans to show that they agree with the plan of care whenever possible. The medicines fridge should be checked to ensure that it is running at the correct temperature to ensure medicines that require refrigeration do not deteriorate. Where a resident is restricted from leaving the home unaccompanied the reason why should be documented in the resident’s plan of care and in accordance with the Mental Capacity Act 2005. The carpet, in the room identified to the deputy manger, should be deep cleaned to remove staining or be replaced. Regular supervision & appraisal of all staff should be commenced as soon as possible to support staff and identify their training needs. The food fridge and freezer temperatures should be checked and recorded daily to safeguard the residents from the possibility of food poisoning. 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 Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 9 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 Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 10 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): 1, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and/or their relatives or representative are provided with sufficient information, to enable them to make an informed choice if the home is the right one for them. St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 11 EVIDENCE: The home provides prospective residents their relatives/representative with a Statement of Purpose and Service Users Guide (both give information about the home) to help them decide if the home is the right one for them. The Statement Of Purpose and Service Users Guide requires updating to include all of the required information in The Care Homes Regulations 2001, schedule 1, and the providers should be mindful to update contact details for Social Services (who manage complaints) and the CSCI so that residents and their relatives or representatives have the correct information. This information also needs to be included in the complaints policy and procedure. Three residents’ care plans reviewed contained a detailed social service assessment and the home’s pre-admission assessment to show that the home could meet their specific health, welfare, and social care needs. It included personal details, relative and GP contact numbers, a past and present medical history, current health care requirements and medications. Private residents are provided with a Terms & Conditions (contract). It is recommended that all contracts include all of the information as detailed in the Care Homes for Older People, National Minimum Standards, Standard 2, include the room/s to be occupied by the resident. The home does not provide intermediate care. St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have their health and personal care needs met. EVIDENCE: Residents’ care plans provide carers with good information about the health and personal care needs of the residents and contained comprehensive care plans that identified needs, desired outcomes and how the outcome was to be achieved. They had been regularly reviewed and updated to reflect the current care needs of the residents. St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 13 Appropriate risk assessments were in place for such things as fall management and mobility, and agreed with the District Nurse for residents who required bedrails to ensure that they were appropriate for the resident’s care and safety. Contact with healthcare professionals such as GP’s, District Nurses and hospitals were recorded to ensure that healthcare needs and treatments were addressed. A district nurse spoken with at the time of inspection said that cares were responsive to instruction and had worked well with them as advised and provided specific equipment and treatment for the care of a bed bound resident. Four residents spoken with said that they were happy with the care and one resident said she was confident that the home would arrange any medical care she needed. The care plans reviewed had not been signed by the resident and/or their representatives to show that residents and/or their relatives were involved in and agreed with their personal plan of care. This was acknowledged by the deputy manager as something that needed to be addressed to ensure that residents were involved in their care planning process wherever possible. It was noted that most, if not all, residents were unable to go out without the support of a carer to ensure their safety. It is recommended that the reason why is documented in the resident’s plan of care, and where possible agreed with the resident or their representative, in accordance, and to comply with, the Mental Capacity Act 2005. Medication policies and procedures were satisfactory at the time of inspection. Only the managers or senior carers, who are trained to do so, administer medication. Part of a medication round was observed and residents received their medication safely and as prescribed. However, The medicines fridge was too warm, the thermometer showed 19 degrees centigrade, on the day of inspection. This must be checked and temperatures recorded daily to ensure that medicines, which require refrigeration, are stored safely between 2–8 degrees centigrade to prevent their deterioration and efficacy. Observation during the inspection showed that staff knew how to protect and promote residents privacy and dignity. Staff spoke to residents in a respectful, friendly, quiet and helpful way and residents said that staff were pleasant and helpful. St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff work hard to ensure that residents experience a safe and homely life style. EVIDENCE: It was observed that throughout the inspection the deputy manager and staff had a warm rapport with residents. Residents were observed coming and going to the office staff took time to listened and reassure them. During the inspection residents were watching TV, listening to music, reading and doing crosswords and residents are able to use the well-equipped gym, which also has a small coffee bar. There are also extensive well maintain gardens, including a sensory garden for residents to enjoy. St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 15 The home does not an activities organiser or a daily programme of activities. However, the deputy manager said that a carer is designated each day to provide three and half hours to support residents with their preferred activities, such a going to the local village or Market Harborough to do some shopping. There is an organist ever two weeks, and festivals and birthdays are celebrated. The home host a slide show every two weeks. Each show focuses on a different resident, showing familiar landmark from their home area and was popular with the residents. One resident is taken to Leicester every three weeks to a specialist hairdresser and to do some shopping. Another resident said she had been taken swimming but would like to do this more often but was regularly visited by family and went out with them. Specific cultural and religious preferences are well supported. The priest regularly visits and provided a service and communion, and everyone can attend if they wish. One resident said that she enjoyed the services, which were fairly well attended. Staff support residents with making choices in their everyday life. All residents spoken with said they got up and went to bed when they wished, were able to choose what they wanted for their meals and were able to have visitors at any time. All meals were prepared in the home’s kitchen by the cook. The kitchen looked clean and well maintained. There were choices at all main meal times. Drinks were provided mid morning and afternoon. Special diets such as diabetic and soft diets were catered for. There were two sittings for main meals. Residents who need help go to the first sitting so that staff have more time to provide the assistance they required. The food provided for lunch looked nutritious, well presented and residents who required help with feeding were given this in an unhurried and unobtrusive manner. There has been a problem with the home being without a cook for a while but this has been resolved and a carer has now taken this on fulltime. The temperatures of fridges in the main kitchen have not been regularly monitored to ensure that food is being kept at the correct temperature. Fridge and freezer temperatures should be checked and recorded daily to safeguard the residents from the possibility of food poisoning. Residents said that the food was very good and that choice and personal preferences were catered for. One resident said that the food was “very good” and that she had “put on weight in the short time she had been at the home”. St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for receiving and responding to complaints are satisfactory. EVIDENCE: The CSCI has received one complaint about the home that the Registered Manager is investigating and will respond to the CSCI in due course. The home has a complaints policy but this requires updating (see under Standards 1-6). Information regarding advocacy services could be made more readily available in the reception area, particularly as the deputy manager indicated that a number of residents had little family contact to support them. The home’s complaints process reflects the local ‘Safeguarding Vulnerable Adults’ policies and procedures. New staff did not have any record of having received ‘safeguarding’ information during their induction period and staff were unclear about correct safeguarding procedures and had not received safeguarding training for about two years, which could potentially put residents at risk. St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 17 Residents’ comments showed that people felt safe and that they could discuss concerns with the manager and staff and that concerns would be addressed. St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a clean and comfortable standard of accommodation. EVIDENCE: The home was clean, safe and well maintained with adaptations to suit residents’ specific needs. It was decorated and furnished to a good standard that creates a comfortable and homely environment. St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 19 Residents’ rooms have en-suite facilities and all have a ‘nurse call’, and were clean and well decorated. Residents were able to bring items of their own furniture and possessions with them to personalise their rooms. All residents’ rooms seen were personalised and reflected their particular interests. Residents have access to attractive, safe gardens with a small well-equipped gymnasium and coffee bar, set away from the main house, which provides an alternative place to go. One room is undergoing a complete refurbishment, including replacing the floor and sanitary ware so that it will be clean and fresh for the next resident to occupy. Another room, identified to the deputy manager had a stained carpet. The deputy manager said they were unable to remove the stains. The carpet requires deep cleaning or replacing for hygienic reasons and to preserve the dignity of the resident. There are sufficient toilets, bathing and assisted bathing facilities, which includes a recently installed Parker bath for residents who require additional assistance with bathing. The home’s health and safety arrangements such as regular maintenance and servicing of equipment, regular fire drills and monitoring heat control valves on hot water taps throughout the home show that the Registered Provider (owner) and Registered Manager are mindful of their responsibilities to make sure that residents live in a safe environment. St Bernards DS0000001825.V365741.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 good. This judgement has been made using available evidence including a visit to this service. Staff at the home are sufficient in number to meet the current residents’ needs, but mandatory staff training must be completed to provide staff with current ‘safeguarding’ information. EVIDENCE: There were 36 residents at the time of the inspection, many had been alcohol dependent at some time, some had difficult behaviours, and require additional monitoring and support by staff, which was recorded in the resident’s care plan. Staffing levels, at the point of inspection, were in line with those suggested by the Department of Health Residential Forum Guidelines to meet the current residents’ needs. During the day there were five staff on the early shift, four staff on the late shift and two care staff at night. There were also ancillary staff such as an administrator, a cook, two cleaners and a maintenance person, which enables carers to concentrate on providing care for the residents. Three staff files were checked during the inspection and showed that there was a satisfactory recruitment process to ensure that residents were well protected. St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 21 Not all of the staff had received all of the mandatory training, but the deputy manager said the manager had a list to ensure all staff training needs were being identified and updated. The induction programme, recorded in staff files, appeared to be very basic and did not demonstrate that new staff had received essential training in areas such as Moving & Handling and safeguarding vulnerable adults. Other staff had received training in specific areas such as Moving & Handling, Medication Management, Challenging Behaviours and ‘whistle blowing’ procedures they had not had ‘safeguarding vulnerable adults’ training for about two years and were unsure of their responsibilities in this area. This should be addressed as soon as possible to ensure that staff have the necessary information to safeguard residents. The deputy manager said all of the care staff had completed National Vocational Qualification (NVQ) in Care. This should be commended and shows the provider and managers’ commitment in ensuring that staff have the necessary skills to give safe care to the residents. St Bernards DS0000001825.V365741.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): 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager and her deputy provide good, supportive leadership to staff, ensuring that residents receive a good standard of care. St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home has a Registered Manager, registered by the CSCI, and demonstrates that she has the necessary skills and is ‘fit’ to manage a care home. The Manager works in a supervisory and management role in addition to care staff numbers. Residents spoke positively about both the deputy and the Registered Manager and named a senior carer, on shift at the time of inspection, as particularly supportive and helpful. Staff had not been regularly supervised (a regular review of staff’s personal and training needs in relation to their work) in the past apart from annual appraisals. Information about staff supervision was unavailable on the day of inspection but the deputy manager said that it was now being done more frequently. The implementation of annual, mandatory training, and regular, recorded supervision and appraisals, should ensure that staff have their training needs identified and that they continue to have the necessary skills to provide a good service for the residents. Health and Safety Policies and Procedures, such as regular recorded fire drills, fire alarm tests and regular equipment maintenance had been completed and showed that the manager was mindful of her responsibilities to make sure that residents live in a safe environment. Residents’ finances were well managed and written records maintained, but two signatures to deposits and withdrawals would further safeguard both residents and staff from mistakes being made. St Bernards DS0000001825.V365741.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 2 3 X X X X X X 3 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 3 X 3 X 3 X X 3 St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP1 Regulation 4 (Schedule 1) 18 (1) (a) Requirement The Statement of Purpose and Service Users Guide should contain all of the information as stated in Care Homes Regulations 2001, Schedule 1. All staff, including new staff during induction, should be provided with ‘safeguarding vulnerable adults’ training. Timescale for action 03/08/08 1 OP18 03/08/08 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 OP2 Good Practice Recommendations It is recommended that all contracts include all of the information as detailed in the Care Homes for Older People, National Minimum Standards, Standard 2, and include the room/s to be occupied. It is recommended that residents and/or their relatives/representatives are involved in and sign care plans to show that they agree with the plan of care. It is recommended that the medicines fridge be inspected DS0000001825.V365741.R01.S.doc Version 5.2 Page 26 2. 3. OP7 OP9 St Bernards 4. OP18 5. 6. 7. OP26 OP36 OP38 to ensure that it maintains the correct temperature. It is recommended that where a resident is restricted from leaving the home unaccompanied the reason why is documented in the resident’s plan of care and is in accordance with the Mental Capacity Act 2005. It is recommended that the carpet, in the room identified to the deputy manager, should deep cleaned to remove staining or be replaced. It is recommended that regular supervision & appraisal of all staff be commenced as soon as possible to identify what staff training needs are required or need updating. It is recommended that fridge and freezer temperatures should be checked and recorded daily to safeguard the residents from the possibility of food poisoning. St Bernards DS0000001825.V365741.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG 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 Bernards DS0000001825.V365741.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!