Inspection on 13/03/06 for St Cecilia

This inspection was carried out on 13th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Cecilia 26/01/09

St Cecilia 17/01/08

St Cecilia 19/05/06

St Cecilia 04/08/05

St Cecilia 31/01/05

St Cecilia 15/07/04

St Cecilia 23/02/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOMES FOR OLDER PEOPLE St Cecilia 29 Nelson Road Branksome Poole Dorset BH12 1ES Lead Inspector Gloria Ashwell Unannounced Inspection 13th March 2006 11:45 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 Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Cecilia Address 29 Nelson Road Branksome Poole Dorset BH12 1ES 01202 767383 01202 767383 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) Mr Robert John Eshelby Ms Carolyn Gwendoline Hazell Care Home 13 Category(ies) of Dementia - over 65 years of age (13), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (13) St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person (as known by the CSCI) under the age of 65 may be accommodated to receive care. 4th August 2005 Date of last inspection Brief Description of the Service: St. Cecilia is registered to provide care for up to 13 older people over 65 years of age with mental health needs. The home is detached and situated in a quiet residential street with access to the shops and amenities of Westbourne. Accommodation comprises 6 single rooms on the ground floor including 4 with en-suite hygiene facilities and 6 rooms on the 1st floor including 1 double room. A large ground floor room provides the lounge and dining room. On each of the 2 floors there is a bathroom and separate toilet. There are sloping gardens to the rear of the property. At the front of the home is a tarmac drive with a seating area. St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was one of the two statutory inspections required in accordance with the Care Standards Act 2000. The previous inspection was on 4 August 2005; since that inspection no complaints against the home have been received or investigated by the Commission. The inspector spoke to 5 residents, and together with the registered manager considered other evidence relating to the National Minimum Standards, as described in this report. This inspection was relatively brief in duration, lasting 3 hours and 15 minutes, and focussed on monitoring compliance with the requirements contained in the report of the last inspection and assessment of other essential standards. Some standards assessed and found met during the previous inspection were not reassessed during this inspection; this report should therefore be read in conjunction with the report of the previous inspection. What the service does well: What has improved since the last inspection? The report of the previous inspection included requirements for the improvement of medicine handling and the complaints procedure; neither has been fully met. St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 4 (Standards 1 & 5 were found met at the previous inspection) The home does not provide intermediate care so Standard 6 does not apply. The home does not always carry out pre-admission assessment of prospective residents and does not write to prospective residents confirming the ability to meet their needs. EVIDENCE: A resident has recently been admitted to the home without benefit of preadmission assessment to ensure the home is properly able to meet her needs. The manager said that this circumstance is not uncommon and that in this instance was the result of emergency admission; the home does not have a written policy/procedure for emergency admission. An associated Immediate Requirement was issued during the inspection. St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 9 The home had obtained a care plan written by the prospective resident’s care manager approx 2 months prior to the date the resident was admitted to St Cecilia’s, but the care plan was prepared for the intention of the person returning to their private address, not a care home, and accordingly provided insufficient information and did not include any form of assessment. St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Staff do not have all written information necessary to ensure the provision of correct care to each resident. Care needs are briefly and sometimes inadequately described in a written plan of care. Many care plans are significantly out of date and inaccurate. Care plans are not based on the findings of robust assessments. The staff’s capacity to effectively monitor and promote the health care needs of service users is compromised by the lack of a suitable set of weighing scales. The home has not adequately implemented policies or procedures for the protection of residents prone to falling or other accident so residents may be at risk of harm. Arrangements for handling medicines must be significantly improved to ensure that residents receive the correct medicines and that all medicines held in the home are properly accounted for. An associated Immediate Requirement was issued during the inspection. Residents feel they are treated with respect and kindness by staff of the home. St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 11 EVIDENCE: Care plan documentation is not suited to recording changes in condition/circumstance and in consequence aspects of care plans are frequently out of date and no longer accurate. The daily records of one resident indicated the necessity for wound care but the care plan made no reference to the condition. A care plan made no reference to a recently sustained fall which occasioned injury, nor did it describe the action to reduce the risk of falls. It provided inadequate information about another serious condition experienced by this resident. Risk assessments do not reliably form the basis for care plans; no nutritional assessment is carried out and residents are not weighed (the home does not have seat scales, and the only set of bathroom scales does not work). The home has not implemented a policy/procedure for risks of falling and does not routinely review these risks following all falls sustained by residents. The home records details of all accidents and has developed but not implemented a formal policy and procedure for the management of accidents to ensure that risks are identified and minimised. One of the care plans sampled made insufficient reference to the management of the service users diabetes, failing to state the ‘safe range’ of blood sugar, indications of possible deterioration in condition and the action to be taken in such event. On 20 April 2006 the registered manager wrote to the Commission stating, “we did not have either the training or the equipment to manage her diabetes, which was why the District Nurses from the surgery were responsible for the monitoring.” Contrary to guidance issued by the Royal Pharmaceutical Society staff of the home pre-dispense prescribed medicines, the home does not have suitable storage and transportation facilities; storage comprises a small wooden cabinet in a confined space and there is no trolley. Medicine administration records (MARs) did not state the allergy status (to medicines) of each resident and handwritten amendments to the printed MARs were not signed, dated and countersigned by a person who had checked the entry for accuracy. The reason for ‘as required’ administration was not always stated on the MAR. MARs did not clearly indicate which prescribed medicines had been subsequently discontinued on the instructions of the prescribing doctor. When a variable dose was prescribed the records did not state the amount administered on each occasion. St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 12 Controlled Drugs have been used in the home although it is without the proper recording and storage facilities necessary for these medicines. On 20 April 2006 the registered manager wrote to the Commission stating that when Controlled Drugs were used in the home, they were pre-dispensed into ‘dosette boxes’; the practice of pre-dispensing is contrary to current standards and subsequent to this inspection the home has been visited by the Commissions Pharmacy Inspector who has provided further guidance and advice on the safe handling of medicines. It is recommended that the home record for each resident a list of all prescribed medicines and the purpose for which they have been prescribed, together with known side effects. Arrangements will be made for the pharmacy inspector of the Commission to visit the home to provide guidance on medicine handling. Residents said they are treated with respect and their privacy and dignity is protected at all times. St Cecilia DS0000004074.V286132.R01.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): 14 & 15 (Standards 12 & 13 were assessed and found met at the previous inspection) Opportunities should be improved for residents to exercise as much choice and control over their lives as possible within the constraints of their mental/physical health conditions. Arrangements for meal provision should be improved to provide residents with opportunities for choice and meal selection. EVIDENCE: The registered manager purchases, delivers and prepares the food; the home does not employ a cook. Meals are determined by a 3 week repeat menu; there is no choice of meal and meals are provided ‘plated’ i.e. residents are unable to serve themselves with any of the foodstuffs. The manager explained that “we find it easier to stick to a set menu”. Most residents eat at the single large dining table; meals are provided in bedrooms for those who prefer this; residents requiring assistance to eat remained in armchairs in the lounge area. The table was not laid with sauces and cruets and cold drinks were provided in mugs. No fresh fruit is left in St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 14 residents areas for them to help themselves as they wish, nor are cold drinks jugs and glasses routinely made available in the lounge. St Cecilia DS0000004074.V286132.R01.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 & 18 The complaints procedure does not provide sufficient and accurate information so persons wishing to make complaint may not have accurate or adequate information on the procedure to follow. The home does not have an appropriate policy/procedure for the prevention of abuse and staff have not received training in this subject. In consequence neither the manager nor staff have sufficient knowledge to properly protect residents from risks of abuse. EVIDENCE: The complaints policy and procedure is described in the service user guide but must be improved to include the contact details of CSCI, Dorset Social Care & Health and the local Primary Care Trust and to state that complaints may be referred to CSCI at any stage i.e. not only when it has been investigated by the home but the complainant remains dissatisfied. A register for the recording of complaints must be obtained. The manager showed to the inspector a written procedure for adult protection which provided incorrect guidance, directly conflicting with the accepted procedures as described in the Department of Health document No Secrets: www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGui dance/Publications St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 16 The inspector explained the significance of the inaccuracies and the risks at which they placed residents. This report contains an associated requirement, and the recommendation that the registered manager and staff undertake training in the understanding of abuse, and its consequent management. On 20 April 2006 the registered manager wrote to the Commission stating, “the home’s abuse policy did need reviewing but most staff have had training including myself, although the training was done in May 2003 and is now due for renewal”. St Cecilia DS0000004074.V286132.R01.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, 22 & 26 The home appears shabby, is poorly maintained, minimally equipped and not ideally suited to the needs of residents. The home is poorly heated. An Immediate Requirement was issued for the improvement of the ambient temperature in resident areas. EVIDENCE: The home has not been assessed for suitability by an Occupational Therapist. The furnishings and premises are shabby and minimally equipped; there is no lift between the floors, no mechanical lifting equipment, extremely basic bath aids and many aspects of the premises require updating and repair. St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 18 A curtain rail hung loose from the wall in one bedroom, the door handle to a bedroom was almost falling from the door, stained and threadbare armchairs with damaged seating were in use, the manager said that many of the wooden dining chairs had loose joints, a perished rubber bath mat was in use and bedding was frequently threadbare. Many windows are ill fitting and permit draughts; some cannot be fully closed. The home was very cold on the day of inspection (the day was unusually cold for the time of year, with outside temperatures not rising above 4C). Residents appeared cold; all wore a number of layers, including cardigans and some wore jackets. Residents able to express an opinion said they were cold. The manager said that the heating was at maximum, but that a plumber was needed to improve the circumstance; many radiators were no more than slightly warm. During the inspection a portable fan heater was brought into the lounge. An Immediate Requirement for the improvement of heating was issued and concerns were referred to the Environmental Health Department. The rear garden is sloping and presents many hazards, including piles of builder’s rubble. There are insufficient hand rails to assist frail vulnerable elderly people to negotiate the steps and sloping paths. St Cecilia DS0000004074.V286132.R01.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 Care staff undertake all housekeeping tasks within the home resulting in residents receiving an inconsistent and unsatisfactory service because the manager and care staff must divide their time between care practices and household tasks and may experience difficulty in so doing. The home’s recruitment systems do not adequately protect residents from the risks of potentially unsuitable staff being employed. In this regard an Immediate Requirement was issued during the inspection. The home does not meet the recommended standard for at least 50 of care staff to hold a National Vocational Qualification in care. EVIDENCE: The home does not determine staffing levels in a systematic way which should be determined by dependency assessment in accordance with the Staffing Forum calculation. During most mornings there are 3 staff on duty, during most afternoons there are 2 and at night there are 2 care workers on duty with one sleeping and the other wakeful. Care staff also undertake all cleaning, cooking and laundry work. St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 20 From examination of records and discussion with the manager there was evidence that a new member of staff had recently commenced work in the home prior to the home receiving CRB disclosure and POVA 1st check. There was no record of the interview of this person, the history of employment was incomplete, and references were undated and had not been obtained from any previous employer. At present none of the 10 care staff currently employed by the home hold a National Vocational Qualification in care; none are at present training for this qualification – the standard is for at least 50 of the care staff to hold an NVQ in care. St Cecilia DS0000004074.V286132.R01.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): 35, 37 & 38 (Standard 31 & 33 were found met at the previous inspection) There must be robust evidence that the system for managing monies held on behalf of residents properly safeguards their interests. The Commission has not received regular reports about the conduct of the home so the home is not complying with the requirement to provide monthly reports of the home’s conduct to the Commission. Fire safety equipment is not all properly maintained so in the event of fire in the home, it may not be properly contained and may place service users and staff at risk of harm. Evidence of the safety of specified items of equipment must be provided to ensure the protection of service users and staff. St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 22 EVIDENCE: The manager said that the registered person manages personal finances on behalf of one of the residents but does not leave any associated records or monies in the home, so the inspector was unable to assess compliance for this aspect. This report therefore contains a requirement for the registered person to provide the necessary evidence to the Commission within the stated timeframe. The Registered Person has not provided reports to the Commission at the monthly frequency required by the Care Standards Act 2000; this report contains an associated requirement. A short dated requirement was issued during the inspection for assessment of risks associated with falling from insufficiently restricted upper floor windows. The home has recorded a fire safety risk assessment of the premises; the manager informed the inspector that all identified risks have been resolved. The home provides staff with fire safety training, and holds periodic fire drills. Records indicated that regular tests and checks of fire safety equipment had not been carried out at the required frequencies. An Immediate Requirement was issued during the inspection to ensure that the frequency of fire safety equipment checks/tests is in accordance with the standards set by Dorset Fire & Rescue Service. The manager has compiled some information regarding the control and use of cleaning substances, but has not recorded the names of the various substances and has not obtained the relevant product data sheets. It is required that comprehensive COSHH information be compiled and maintained up to date. The manager has assessed some safety aspects of the premises but has not included an up to date assessment of the gardens and other grounds which at the time of the inspection contained piles of builder’s rubble which could pose risks of falling to service users, and had insufficient railings to ensure the safety of persons using the sloping areas. A comprehensive safety assessment of the premises and working practices must be compiled. On 20 April 2006 the registered manager wrote to the Commission stating, “an assessment of the gardens and grounds has been compiled”. St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 23 At the time of this inspection records were not available for examination to confirm the safety of the gas and electrical installations; these documents must be provided to the Commission within the date stated in this report. St Cecilia DS0000004074.V286132.R01.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 X X 1 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 1 X X 1 X X X 1 STAFFING Standard No Score 27 2 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 1 X 2 1 St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 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 OP3 Regulation 14 Requirement No new resident may be admitted to the home without a comprehensive pre-admission assessment being recorded in advance. Prior to admission of any new resident the home must confirm to that person in writing that the home will be able to meet their assessed needs. The registered person shall ensure that residents care plans contain sufficient detail to provide clear guidance to staff on the actions to be taken to meet their care needs. The care plans of service users with diabetes must provide comprehensive reference and guidance to management of the condition. Comprehensive risk assessments including for nutrition and falling must form the basis for care plans. Storage facilities and written records associated with Controlled Drugs must be DS0000004074.V286132.R01.S.doc Timescale for action 13/03/06 2. OP4 14 13/03/06 3. OP7 15 13/04/06 4. OP7 13 13/04/06 5. OP9 13 13/04/06 St Cecilia Version 5.1 Page 26 6. OP9 13 7. 8. OP9 OP9 13 13 9. OP9 13 10. OP16 22 11. 12. OP16 OP18 22 13 13. OP19 13 14. OP19 16 15. St Cecilia OP22 23(2)(n) provided if these medicines are to be used in the home. When a variable dose is prescribed the amount actually administered on each occasion must be recorded. Secure facilities must be used for the transportation of medicines about the home. Handwritten entries in medication instructions must be signed and dated by the writer and countersigned by a member of care staff who has checked the entry for accuracy. There must be robust evidence that medicines are accurately administered and recorded in accordance with the instructions of the prescriber and with current guidelines for the control and administration of medicines. The complaints policy and procedure must be improved to include contact details of CSCI, Dorset Care & Health and the local Primary Care Trust. A similar recommendation was included in the report of the previous inspection. A register for the recording of complaints must be obtained. The home must develop, implement and thereafter properly adhere to effective and appropriate Adult Protection procedures. The rear garden must be cleared of builder’s rubble and other hazardous items and must be made safe for use by residents. A programme of routine maintenance and renewal of the fabric and decoration of the premises must be produced and implemented with records kept. Aids, hoists and assisted bath facilities must be provided in DS0000004074.V286132.R01.S.doc 13/03/06 13/04/06 13/04/06 16/03/06 01/05/06 01/05/06 01/05/06 13/05/06 13/04/06 13/04/06 Page 27 Version 5.1 15. OP25 23(2)(p) 16. 17. OP25 OP29 23(2)(p) 19, Sch 2 18. OP35 16(2)(l) 19. OP37 26 20. OP38 23(4) 21. 22. OP38 OP38 13 13 23. St Cecilia OP38 13 accordance with the assessed needs of each resident. A satisfactory ambient temperature must at all times be maintained throughout the registered premises. A room thermometer must be displayed in the lounge/dining room. There must be evidence that the home operates a robust recruitment system; new staff must not commence work in the home without evidence of suitable CRB disclosure and POVA 1st check, and provision of at least 2 references including one from the most recent employer. The registered person must provide to the Commission robust evidence that the system for managing monies held on behalf of residents properly safeguards their interests. The registered person must arrange for the home to be visited at least once each month to inspect the premises, interview, with their consent, residents and staff and must provide to the Commission a written report on the conduct of the home. Fire safety equipment must be tested/checked at the required frequencies and accuate records must be kept of these tests/checks. Comprehensive COSHH information must be compiled and maintained up to date. A comprehensive safety assessment of the premises and working practices must be compiled. Documentary evidence confirming the safety of the gas DS0000004074.V286132.R01.S.doc 13/03/06 16/03/06 13/03/06 01/05/06 13/04/06 16/03/06 01/06/06 01/06/06 01/05/06 Page 28 Version 5.1 and electrical installations must be provided to the Commission. 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. Refer to Standard OP3 OP8 Good Practice Recommendations A policy/procedure for emergency admission should be developed and implemented. The weight of each resident should be recorded at least monthly, with observations regarding any changes in weight. The home should record for each resident a list of all prescribed medicines and the purpose for which they have been prescribed, together with known side effects. When a medicine is prescribed for administration ‘as required’ the administration record should clearly state the reason for which it is required. The medicine administration records for each resident should clearly state any allergy to medicines, or ‘none known’. Medicine storage facilities compliant with the guidance of the Pharmaceutical Society should be obtained and installed at the earliest opportunity. Medication administration records should clearly indicate which medicines have been discontinued, including the date on which this change took place. Residents able to do so should be enabled to serve themselves with food at the table, and should have available cruet and sauces. In advance of each meal residents should be offered a choice of menu. Fresh fruit and drinks should be readily available to residents. A cook should be employed. 3. 9 4. 5. 6. 7. OP9 9 OP9 9 8. 9. 9. 10. OP14 OP15 OP15 OP15 St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 29 11. 12. OP1818 OP22 13. 14. 15. OP22 OP27 OP27 The registered manager and staff should undertake training in the management of allegations or suspicions of abuse. The premises should be assessed by a suitably qualified individual such as an Occupational Therapist. This recommendation was also included in the report of the previous inspection. A passenger lift should be installed. Care staff should not be diverted to tasks different to their main purpose of providing personal and social care to residents. Staffing levels should be determined by use of the Staffing Forum calculation. St Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Cecilia DS0000004074.V286132.R01.S.doc Version 5.1 Page 31 - 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. 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