Inspection on 17/01/08 for St Cecilia

This inspection was carried out on 17th January 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Cecilia 26/01/09

St Cecilia 19/05/06

St Cecilia 13/03/06

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 Catherine Churches Key Unannounced Inspection 17th January 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 Cecilia DS0000004074.V358234.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 Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Cecilia Address 29 Nelson Road Branksome Poole Dorset BH12 1ES 01202 767383 01202 767383 st.cecilia29@hotmail.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) Mr Robert John Eshelby Ms Carolyn Gwendoline Hazell Care Home 15 Category(ies) of Dementia - over 65 years of age (15), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (15) St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named person (as known by the CSCI) under the age of 65 may be accommodated to receive care. Only independently mobile residents may be accommodated in the second floor rooms. 19th May 2006 Date of last inspection Brief Description of the Service: St Cecilia is registered to provide care for up to fifteen older people over 65 years of age with mental health needs. The home is detached and situated in a quiet tree lined residential street. There is easy access to the shops and amenities of Westbourne. Accommodation comprises of six single rooms on the ground floor four of which have en-suite facilities and a further six rooms on the first floor, one of which is a double room and one of which has an ensuite facility. There is a bathroom and WC on both the ground floor and the first floor. The second floor has recently been refurbished and now provides two single bedrooms and a bathroom as well as a sleeping in room for staff. The home has recently been recarpetted. There are secluded gardens to the rear of the property and a tarmac drive at the front of the home with trees, shrubs and a seating area. The current level of fees for personal care and accommodation at St Cecilia is £494 based on the local authority rate of payment for care services. St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection, which took place on 17th January 2008. In total four and a half hours were spent in the home undertaking the inspection. Ms Hazel, the registered manager was present throughout the inspection. The inspection took place as part of the regular, programmed inspection schedule for the home. The last inspection was May 2006. The purpose of this visit was to monitor the homes compliance with National Minimum Standards and with requirements and recommendations made during the previous inspection. Also, to check that the home is run in a satisfactory manner and that the people who are living in the home are properly cared for. The premises were inspected and a number of records examined. Time was also spent time observing routines within the home and talking with residents, visitors and staff. The manager also completed the CSCI Annual Quality Assurance Assessment to a good standard and much of the information provided was used to assist the inspection process. What the service does well: What has improved since the last inspection? Three requirements and six recommendations were made as a result of the last inspection. Two requirements and two recommendations have been fully met. This has resulted in safer medication handling and evidence that the gas St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 6 and electrical installations are safe. The information available to prospective residents and their representatives has improved and the building has been assessed by an Occupational Therapist and the recommendations have been implemented which assists residents around the building. 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. The summary of this inspection report can be made available in other formats on request. St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 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.V358234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good; this judgement is made using available evidence. The admissions process is such that all residents have a pre-admission assessment and care management plan provided by the funding local authority prior to admission, where such information has been inadequately provided, the registered manager ensures that assessment information is gathered before offering the resident admission to the home. EVIDENCE: St Cecilia holds a contract with the Local Authority for all but one of its rooms, as such, the Borough arranges all admissions and residents contractual arrangements are agreed with them at the time. All residents are however St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 9 issued with a letter from the home confirming that based on the assessment, the home can meet their needs, this letter also details a statement of the Terms and Conditions of Residency at St Cecilia. Care files for two residents were examined; both held assessment information and care plans provided by the local authority as well as additional information obtained by the manager. St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care Plans for residents who live at St Cecilia are detailed and informative although some areas of need have not been covered meaning there are some weaknesses. This means that staff may have insufficient information to provide a good level of care and the home also cannot demonstrate that they are aware of each persons needs and have provided the required care. The home ensures that resident’s healthcare needs are met through seeking appropriate input from GP’s and other healthcare professionals. The ethos in the home is one of respect for the residents living there. This means that the residents feel settled at the home and their privacy is respected. St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 11 EVIDENCE: Resident’s needs are assessed and reviewed appropriately in relation to all health and welfare needs. St Cecilia is provided with a care management care plan from the local authority for each resident, this is used for information prior to and on admission, the registered persons then ensure that a care plan is written specifically appropriate to the resident’s needs whilst living at St Cecilia. Care plans examined detailed how needs are to be met in relation to personal care, physical and mental health and social care. It was evident that resident’s needs are considered individually and care plans reflect personal choices such as their preferred time of waking, daily routines, likes and dislikes. At the previous inspection nutritional assessments had been implemented but these were found to have been stopped again at this inspection. There was also very little or no information found regarding skin integrity/pressure area care, moving and handling needs and specific information regarding mental health or dementia needs. RE moving and handling it was also noted that the home does not have a hoist for general/emergency use which has resulted in staff picking residents up when they have fallen. Daily records are written by staff for each resident, these provided a detailed report of the resident’s daily routines, lifestyles and any significant health or welfare problems. Care plans and daily records are written in a manner that uses easy to understand language and is respectful of the resident’s needs and how they are managed. Issues with medication were identified and referred to the Commissions’ Pharmacy inspector to provide advice and support. During conversations with a number of residents and visitors, they confirmed (where they were able to) that they were happy with the care they received. They also confirmed that they feel respected by staff and are able to maintain their privacy when receiving personal care or visits from professionals such as GP’s and solicitors, family and friends. It was observed that staff knock on doors before entering and that residents preferred form of address is recorded and used. St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social, cultural and leisure activities provided by the home are consistent with the resident’s abilities to engage. Residents are supported in maintaining contact with their friends and family and in making decisions about their lives in the home and it was evident that a caring staff group provided choices in daily routine and level of activity. Residents are provided with a variety of appetising meals that meet their individual tastes and dietary requirements. EVIDENCE: It was evident from discussion with residents that they were satisfied with the level of activity in the home. Care records also demonstrated the extent to which residents engage in social or leisure activity in the home and with visits from friends and families. St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 13 Some residents have varying degrees of dependency and complex needs and many are unable to make decisions and choices about their daily lives although it was apparent that staff provide choices with regard to daily routine and level of activity. Residents were observed in the lounge area and with a continual staff presence there was a supportive, relaxed and friendly atmosphere. Meals are provided to residents in the dining room of the home where a large ‘farmhouse’ style table enables them to eat together in a sociable setting. A menu details what meal is to be served each day and although residents do not directly have a choice of meal, their likes and dislikes are known and an alternative would be offered where it is known that the resident does not like the meal of the day. Care staff do the home’s catering and at previous inspections the recommendation that a cook should be employed to free up care staff time has been made. Instead additional care staff hours have been utilised, there are now four members of staff on duty in the mornings (from Monday to Friday), one to cook, two to care and the manager. Care staff also provide the evening meal although this does not take so much preparation time as it consists of a lighter meal or sandwiches. Mrs Ruth Eshelby has a higher diploma in Nutrition and Mr Eshelby confirmed that the menus have been designed around sound principles of nutrition and calorific value. St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. St Cecilia has a satisfactory policy and procedure for the making of complaints. This means that residents and others involved in the home who may wish to make a complaint should feel confident that they would be listened to and matters of concern will be acted upon. Procedures for responding to suspicions of abuse are held in accordance with Department of Health guidance, meaning that any allegations of abuse can be managed effectively. EVIDENCE: St Cecilia has a satisfactory complaints procedure that is displayed in the home as well as included in the Welcome Pack. Those spoken to confirmed that they knew how to make complaints and would feel able to do so should the need arise. No complaints have been made either to the home or to CSCI since the before that last inspection. St Cecilia has available for staff a copy of the local authority guidelines on managing and reporting any allegations of abuse or poor practice. Additionally the home has it’s own policy which informs staff of the appropriate procedures and to refers them to the local authority guidelines. The manager confirmed St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 15 that all staff had received appropriate training but there was no recording system in place to allowing checking and tracking of this or to easily identify when update training is required St Cecilia has available for staff a copy of the local authority guidelines on managing and reporting any allegations of abuse or poor practice. Additionally the home has it’s own policy which has been amended since the last inspection to inform staff of the appropriate procedures and to refer them to the local authority guidelines. Four of the nine care staff employed have received training in adult protection although Carolyn Hazell confirmed that this needs up dating and other staff need to attend (See also standard 28) St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 16 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, 22 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical environment of the home is comfortable but somewhat tired looking. The increase in registered numbers means that space in some areas, especially the kitchen, is very limited for the number of people for which the home provides care. It is also lacking in some pieces of equipment, which could affect resident care. A number of the fixtures and fittings need replacing. If not attended to soon, this could affect the quality of life of those living in the home. EVIDENCE: Over the last eighteen months or so Mr Eshelby has refurbished some areas of the home and has provided new carpet in the ground floor as well as creating two extra bedrooms and a new bathroom on the second floor. St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 17 Dorset Fire and Rescue Service have visited the home and confirmed that it complies with their requirements. The manager confirmed that the owner is aware that certain areas of the home are in need of refurbishment. The manager was not able to provide a clear plan as to how this was to be addressed. A tour of the premises highlighted the following issues: • • • • • • • • • • • • Bedside lamp missing in one room. Later found in staff sleep in room. Staff sleep in room poorly equipped with only a mattress on the floor and no covering on the velux window. Many of the bedrooms did not have extending cables from the call system box in the room. In many cases residents would not be able to summon help from the bed or chair. There was no lock on the door of the second floor bathroom. (This could affect privacy for residents) Many of the vanity units in the bedroom were old and damaged. (Potential to harbour infection). Some pieces of bedroom furniture were old and in need of attention to ensure doors/drawers etc closed properly. The ceiling in one of the first floor bedrooms was badly damaged and in need of repair. The ceiling in the first floor bathroom was also badly damaged. Some tiles in the first floor bathroom had fallen off the wall or were damaged. The first floor laundry cupboard door was not locked and the key was reportedly lost. This despite a Fire Brigade notice that it should be kept locked when not in use. In the ground floor bathroom the bath panel was broken and the floor was worn and had holes in it (this has the potential to harbour infection). The manager advised that new flooring had been ordered. In order to accommodate the new rooms on the second floor the manager’s office has been moved outside to another building. This is equipped well except for the fact that there is no direct contact between this building and the home itself: if staff need the manager they have to come outside of the main home. Also the manager is distanced from the day-to-day running of the home and opportunities to observe staff and residents. Laundry facilities consist of a domestic washing machine and a domestic tumble drier in an out building. Care staff are responsible for laundry. Clean laundry is sorted on the dining table and ironing is also undertaken by staff in the dining room area of the home. A cleaner is employed for 8 hours per week mainly to carry out shampooing of carpets. The care staff are responsible for all other cleaning. The manager also stated that she had spent some time the day DS0000004074.V358234.R01.S.doc Version 5.2 Page 18 • • St Cecilia before the inspection shampooing carpets as the home has to care for a number of people with continence difficulties. We were advised by the manager that the majority of these items had already been identified by both herself and Mr Eshelby and that an action plan was in place to address these matters as a matter of priority. A letter was received on 25th February confirming that works had been completed or were underway. St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The deployment and number of available staff is minimal when taking into account the tasks they are responsible in addition to caring tasks. There is a danger that residents needs will not be fully met. Staff have experience in caring for the elderly and are undertaking training. This means that attention is being given to developing staff abilities and competencies although as yet the minimum standard of 50 staff trained to NVQ level 2 is not met. Recruitment practices could be improved to better support and protect the people living in the home. EVIDENCE: Care staff are responsible for the home’s catering, laundry and cleaning as well as providing all the care for residents. Previous inspections have recommended that a cook should be employed to free up care staff time. St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 20 Instead additional care staff hours have been utilised, there are now four members of staff on duty in the mornings, one to cook, two to care and the manager. The manager does not work at weekends so there is less assistance for staff at the weekend. Care staff also provide the evening meal although this does not take so much preparation time as it consists of a lighter meal or sandwiches. At nights, from 8pm till 8am there is one waking member of staff and one sleeping in and on call. This is most unusual in a home of this size and for this client group, especially as residents sleep on three different floors. Six out of the twelve care staff either have NVQ level 2 or are studying for the qualification. One person also has level 3 and 2 people are studying for this. Staff records were examined for two recently appointed members of staff. Records demonstrated suitable checks had been undertaken prior to staff commencing duties in the home. References were not complete for one person. An application form contained very little information for another person. Employment histories were not always clear. Induction in accordance with Skills for Care standards had been carried out. A letter was received on 25th February confirming that two waking night staff will be employed from March 2008 and this will also relieve day staff of some of the domestic duties currently carried out during the day. St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has a good rapport with residents and relatives and extensive experience in caring for the elderly. St Cecilia is run in the best interests of residents. However, the Quality Assurance system and other management systems cannot always evidence this. Quality assurance programmes and audits are in place although would benefit from development to ensure controlled measurement of care and services provided in order that the home meets its expressed aims and objectives. Sound practices and procedures are in place regarding resident’s finances. St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 22 The health, safety and welfare of residents and staff is potentially being put at risk as the home was unable to evidence that all staff were up to date with required training. EVIDENCE: Carolyn Hazell is registered with the Commission to manage the home on a daily basis with the support of Mr Eshelby and of senior care staff. Ms Hazell has a good rapport with residents and relatives and extensive experience in caring for the elderly. Through discussion and observation it was evident that she is lacking in time for some areas of management and administration. Due to the staffing in the home she often helps with various tasks and this takes her away from completing records such as care plans, staff records and quality assurance. The difficulty in communicating with the home from her office also plays a significant factor not only in time management but also from the point of view safe working alone. Quality audits are carried out although at random intervals, records of the audits demonstrated that aspects of the homes cleaning schedules, care practices, daily records and kitchen stock rotation had been audited; any corrective action needed was identified and the records demonstrated that this had been carried out; the audits have not lead to establishing a development plan. This has been raised at previous inspections. The Manager confirmed that residents are encouraged to retain control of their finances for as long as possible. Where they state that they no longer wish to or they lack capacity to do so, then the home ensures that appropriate persons are available to take on this role. She confirmed that the home does not have any involvement with resident’s finances and does not hold any cash or valuables on anyone’s behalf. Mr Eshelby has continued to make the required monthly reports on the home as required by Regulation 26 of the Care Homes Regulations. Examination of records of testing and maintenance of fire fighting equipment, alarm systems and emergency lighting demonstrated that these are undertaken at the required intervals. A record of fire drills demonstrates that these are carried out regularly and include evacuation of the premises. Staff training in fire prevention and the action to take in the event of a fire was also satisfactory. Analysis of staff training records to ensure training was up to date for moving and handling, health and safety, basic food hygiene and infection control was hampered as there was no master record of when staff had been trained or were due for refresher training. St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 23 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 1 8 1 9 X 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 1 X X 1 X X X 2 STAFFING Standard No Score 27 1 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 1 St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15(1) Requirement Timescale for action 30/03/08 2. OP8 12(1) 3. OP18 18(1) 4. OP19 23 The Care plan must set out in detail the actions that must be taken by staff to ensure that all aspects of their health, personal and social care needs are met. Care plans must be reviewed regularly and any changes must be reflected in the care plan. If changes occur before the planned date of review then these must be added to the care plan. All medical/healthcare needs 30/03/08 must be recorded and suitable action taken. Nutritional assessments must be carried out and regularly reviewed. Scales, which can weigh all residents, must be provided. Staff must receive training in the 30/03/08 Protection of Vulnerable of Adults and this must be regularly updated. Records must be available to evidence this. Those items highlighted for 30/06/08 attention in the “Environment” section of this report must be attended to. DS0000004074.V358234.R01.S.doc Version 5.2 St Cecilia Page 25 5. OP22 23 6. OP27 18(1) 7. OP29 19 8. OP33 24(1) 9. OP38 13 Suitable equipment for the safe moving and handling of residents and also for weighing residents must be provided. Sufficient numbers of skilled and experienced staff must be available to ensure the safety and care of residents at all times. There must be evidence that the home operates a robust recruitment system; new staff must not commence work without evidence of suitable CRB disclosure and POVA check. This requirement was first made at the inspection dated 13/03/06 and is repeated for the second time. 17/1/08 This is the third time that this requirement has been made. Further action may now be taken. Further work must be undertaken with regard to quality assurance systems in the home in order to demonstrate that the home is meetings its aims and objectives and is run in the best interests of the residents. Evidence must be available that staff have received up to date training in health and safety, infection control, first aid, basic food hygiene and moving and handling. Records must be available to evidence this. Safe working practices must be implemented and adhered to. 30/06/08 30/06/08 30/03/08 30/06/08 30/06/08 St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 26 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 OP28 Good Practice Recommendations It is also recommended that at least 50 of care staff have attained NVQ level 2 by end of 2006. St Cecilia DS0000004074.V358234.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Cecilia DS0000004074.V358234.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. 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