CARE HOMES FOR OLDER PEOPLE
St Clair House Care Home 32 Basset Road Camborne Cornwall TR14 8SL Lead Inspector
Paul Freeman Announced Inspection 20th February 2006 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 Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 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 Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service St Clair House Care Home Address 32 Basset Road Camborne Cornwall TR14 8SL 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) 01209 713273 01209 610699 stclaircare@yahoo.co.uk St Clair Care Limited Mr David William Maund Mr David William Maund Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th August 2005 Brief Description of the Service: St Clair is a two storey Georgian building has been extended at the rear and is situated close to the town of Camborne where a range of amenities and facilities are available. The home is owned and operationally run by the registered providers Mr and Mrs Maund. The home generally has satisfactory access for people who experience disabilities with bedrooms situated on both floors and a passenger lift is also provided. The access at the front could be improved for individuals who are reliant upon a wheelchair. The ground floor provides two homely communal sitting rooms at the front and rear and an attractive dinning room. The environment is maintained to a high standard and very attractive and well-maintained gardens are at the rear of the home. St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A planned announced inspection took place on 20 February 2006. The purpose of the inspection was to consider some of the key standards that included assessment, care planning, food, staff training and health and safety. The environment, records and documents were also considered. In addition the requirements and recommendations set at the last inspection visit on 15 August 2006 were also considered. Prior to the inspection the providers sent detailed written information to the Commission about the services and facilities provided. In addition written comments were also received from two relatives and two residents at the home. An additional inspection visit also occurred on 2 November 2005 when the improvements to the care planning arrangements were considered. The registered providers, deputy manager, residents and staff were also consulted. The providers, staff and residents fully cooperated and were very helpful throughout the inspection. What the service does well:
Each prospective resident is assessed by the providers to make sure their needs can be met at the home. The assessment also providers information to ensure that care and support is provided in a manner that reflects the individual’s needs and choice. The prospective resident is invited to play a key role in the formulation of the assessment so that detailed information is obtained in order that a suitable plan of care can be established. Relatives or representatives are also consulted and the providers take account of the views and opinions of any professional that are involved with the individual concerned. Residents that had recently moved to the home said they had been able to outline their needs and preference during the assessment process. In addition the residents stated they had been warmly welcomed to the home and been positively helped to settle in their new environment. St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 6 Each resident has a care plan that details their needs and provides staff with information and direction about the care and support required. The plans have recently been improved so that the residents care and support needs are met in a way that promotes their health and well being. Residents’ health is managed very well and health services are promptly accessed when required. Staff monitor health needs on a daily basis and are keenly aware of any changes or indicators of concern. Residents said were confidant about the manner in which their health needs are met and were complimentary about the way staff cared for them during periods of poor health. Residents also stated they were always treated with dignity and respect and felt they had control of their lives. Medicines are stored safely and the staff administering medication has been suitably trained. Residents are also able to administer their own medicines when it is safe to do so. Control drugs are managed satisfactorily and any medicines that are no longer required are disposed of safely. Residents are able to experience a varied life style that reflects their expectations and preferences. Residents said they are in control of their lives and were therefore able to decide how they met their social and recreational needs. The providers also offer a range of activities at the home and in the local community for those that wish to participate. The activities also reflect the interests of residents at the home. Some of the residents choose to arrange their own leisure time. Residents are also able to participate in the local community independently where it is safe to do so. Residents were complimentary about the meals at the home and two described the meals as “wonderful” and “very good”. A varied and nutritional menu is available each day that is seasonally adjusted. The menu reflects the tastes and preferences of the residents and the catering staff regularly consults with the residents about the choices available. The kitchen is well maintained and the staff has been appropriately trained. Good standards of hygiene are also evident and the equipment in the kitchen is also regularly maintained. One resident said about the arrangements “the staff ask you want you want and they are very accommodating”.
St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 7 A suitable policy and procedure is in place for positively dealing with any complaints the residents may have. Residents commented there were no barriers to discussing any concerns or complaints with the providers. The residents were confidant that any issues would be acted upon promptly and resolved in a satisfactory manner. Satisfactory whistle blowing arrangements are also in place for staff to report any concerns about abuse towards a resident to a third party if they feel unable to discuss the matter with the providers. This provides residents with further protection against abuse. The home is decorated, furnished and maintained to a high standard and residents said they were very satisfied with the facilities provided. Many of the residents’ bedrooms have been personalised by the occupants and a good standard of furnishings and furniture is provided. One visitor to the home commented, “It’s like a small, private hotel and their every need seems to be well catered for”. Regular maintenance occurs at the home and the residents were very positive about the efficient service provided when any repairs were required. A number of bathrooms and toilets are located throughout the home and many of the bedrooms have ensuite facilities. Attractive, well-maintained and stocked gardens are located at the rear of the home and this is a popular area for many residents. Appropriate communal space is also located on the ground floor. Sufficient number of staff is employed during waking hours and overnight. Additional staff is on duty for peak hours during the daytime and waking night staff work each night. A staff member also sleeps in to assist with any emergencies and the providers have established reliable on call arrangements when they are not on duty. Residents commented they are very satisfied with the way in which staff undertake their duties and provide the care and support they require. The residents said that staff is flexible, readily available and attentive to their needs. Staff commented they were very well supported at the home and said good team working practices occur. Positive recruitment, selection and vetting practices are in operation for new staff and the providers have well maintained records. The staff at the home is also well trained and the providers have established a suitable training programme for 2006. The staff said there is no barriers to accessing the training they require and each staff member also has a training plan for 2006.
St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 8 The home is run in the best interests of the residents and the providers undertake an annual quality assessment to review the quality of the services and facilities provided. The quality assessment takes account of the views of residents, their relatives or representatives, staff and professional who are in contact with they home. The review for 2006 will take place later in the year but the last assessment indicated there was a high degree of satisfaction about the facilities and the care and support provided. What has improved since the last inspection? What they could do better:
The records about the administration of medication must be improved to make sure an up to date and comprehensive account is in place. This will also make sure that residents’ health is not inadvertently placed at risk. The providers treat any allegations of abuse seriously and all instances are reported to the statutory authorities and where necessary are formally investigated. The policy and procedure about protection does not reflect the steps the providers would take and therefore requires improvement. The home does not have any sluice facilities and these need to be installed at the earliest opportunity. The flooring on the first floor also requires attention to make sure it does not present any form of risk to residents. The providers said they were establishing an improvement plan to address these issues. The storage arrangements at the home are not adequate although the providers have taken certain steps to try and improve the situation. The
St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 9 providers are establishing plans to make sure that adequate storage is provided throughout the home. 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 Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 10 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 Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 11 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 and 6. The assessment arrangements continue to improve to make sure that needs preferences and choices of the residents can be met. EVIDENCE: The providers assess each prospective resident in order to obtain a clear understanding of their needs and to be satisfied the services and facilities available meet the needs of the person concerned. The assessment also takes account of the individual’s choices and preferences. Each prospective resident is invited to play a key role in the formulation of the assessment and their relatives or representatives are also consulted wherever possible. In addition the views and assessments of any professionals in contact with the prospective resident are also taken into account. Each assessment is recorded and provides key information for the care plan to make sure the care and support needed is provided in a manner that promotes health, safety and the individual’s choice.
St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 12 Following the last inspection the providers have improved the quality of the assessments that are undertaken so that a comprehensive picture is obtained. There continues to be some instances where more detail is required in order that a full picture of need is in place. The providers stated they are in the process of improving the current assessment format to assist this goal. Residents that had recently moved to the home were very positive about the assessment arrangements and the manner in which they were welcomed and helped to settle in their new environment The providers do not offer a dedicated intermediate care or rehabilitation service. However it is evident that every reasonable step is taken to promote residents independence. St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 13 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 and 10. The care planning arrangements have improved and provided staff with appropriate advice, guidance and direction about the care and support required by the resident. Good arrangements are in place to meet residents’ health needs. The records about the administration of medicines are not satisfactory and require improvement to make sure that residents are not placed at risk. EVIDENCE: Each resident has a care that details summarises the care and support they require. The staff said they found the plans to be helpful and provided positive guidance about the care and support required by residents. Residents commented they were very satisfied with the manner in which staff undertake their duties and found the staff to be flexible and responsive to any requests they made. The providers have improved the care planning arrangements in recent weeks to make sure that residents needs can be met in the most appropriate manner that also takes account of their wishes.
St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 14 The care plans therefore provide the staff with clear information, direction and guidance about the resident’s needs and most appropriate way to provide the care and support required. The records demonstrate that care plans are reviewed with the residents on a regular basis. In certain instances the information provided could be written in a manner that provides clearer direction and guidance for staff. This will make sure staff have concise information about the resident’s wishes and needs. Residents’ health needs are met to a high standard. It is evident that health services are accessed promptly when required and the practices at the home promote good health. Residents said they were very confident about the manner in which their health needs were catered for and that assistance was provided whenever required. Medical practitioners and nurses regularly visit the care home when required and residents’ health is closely monitored each day by the staff. Residents were also very positive about the treatment they receive at the home. Residents said they were always treated in a respectful and dignified manner and one said, “the owners are very kind and understanding and I feel they do there best for all of us”. Residents are also able to manage their own medicines when it is safe to do so. Where the providers assist residents medicines are kept in secure facilities and the staff administering medication has been trained. Good arrangements are in place to dispose of medicines that are no longer required and control drugs are managed according to the standards required. The records do require improvement to make sure that a comprehensive and up to date account is in place. Currently certain records are incomplete and others lack clarity. It is clear the requirement and recommendation set at the last inspection have been acted upon but further improvement is required. This will make sure that residents health and well being are not potentially compromised. St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15. Residents experience a lifestyle that provides a stimulating and varied experience that matches their expectations. Residents are provided with a wholesome and nutritional diet that reflects their choices and preferences and promotes good health. EVIDENCE: Residents said they were very satisfied with the lifestyle they experience at the care home. Residents stated they felt in control of their lives and were positive that their independence was encouraged and not compromised. Residents are able to participate in a wide range of activities and pastimes at the care home and in the local community. A range of activities is provided that reflect residents interests at the home and residents only join in if they wish. Some of the residents said they chose to arrange their own pastimes and were able to do this without any interference. There are also no restrictions to residents accessing community opportunities when they wish and where it is safe to do so. A varied and nutritional menu is provided at the home that reflects residents’ choice and preference. The menu is also seasonally varied and residents have a choice at each mealtime.
St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 16 Qualified cooks are employed at the home and the kitchen was found to be clean, hygienic and in good order. Appropriate measures are in place regarding health and safety and the kitchen equipment is regularly maintained and serviced. Residents were very complimentary about the quality, variety and quantity of the meals, which they said, were, “wonderful”, “very good” and one stated “the staff ask you what you want and they are very accommodating”. The catering staff also regularly consults with residents about menu and their choices and preferences. St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 17 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 and 18. Positive arrangements are in place to deal with any complaints or concerns residents may have. The arrangements for protecting residents against abuse are robust but the policy and procedure is not satisfactory and requires improvement to make sure residents are safeguarded. EVIDENCE: The care home or the Commission following the last inspection has received no complaints. The providers have established a satisfactory policy and procedure for dealing with complaints and are committed to resolving any concerns at the earliest opportunity. Residents commented there were no barriers to approaching the providers about that any issues, concerns or complaints they had. The residents also said they were confidant that any issues would be dealt with promptly, efficiently and resolved in a satisfactory manner. The records show the providers have a clear understanding about the action to take if any allegations are made about abuse to residents. All allegations are reported to the statutory authorities and where necessary a formal investigation takes place. The policy and procedure does however require amendment, as it does not accurately reflect the steps the providers would take or the guidance provided by the Department of Health. St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 18 The providers have also established satisfactory whistle blowing arrangements. This provides staff with the opportunity of reporting any issues to a third party where they feel unable to report the matter to the providers. This provides residents with a further safeguard against abuse. St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 19 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 The standard of the environment is very good and provides residents with an attractive and homely place to live. However the floor on the first floor require attention to make sure that residents health and well being is not compromised. The home is clean and hygienic but sluice facilities need to be provided to also make sure residents health is not compromised. EVIDENCE: The home is maintained to a high standard and an annual programme of maintenance and replacement of equipment and furniture is in place. Residents commented they were very satisfied with the facilities provided and said the providers responded promptly and efficiently to any repairs that were required. There are also very well maintained and attractive gardens at the rear of the home that is a popular area for many of the residents. A car park is also provided at the rear. St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 20 Residents said they were very satisfied with their bedrooms. The bedrooms are situated on the ground and the first floor and have been personalised by the occupants and a good standard of furnishings and furniture is provided. One visitor to the home commented, “It’s like a small, private hotel and their every need seems to be well catered for”. Residents are able to lock their rooms if they wish and secure facilities are also available within their rooms. A range of toilets and bathrooms are provided throughout the care home that meets with the national minimum standards and many of the bedrooms also have ensuite facilities. The floors on the first floor are unstable in certain parts and require attention or replacement to make sure that residents and staff are not placed at risk. The providers have taken steps to ensure that a range of disability aids and equipment is provided at the home to help residents maintain their independence but the home does not have any sluice facilities. Theses facilities need to be provided to make sure that residents health and wellbeing is protected from infection. Requirements were set at the last inspection about the floors on the first floor and the need to provide a sluice. The providers have established an improvement plan to comply with the requirements. It is planned the work will commence in the next year. St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 21 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, 29 and 30. Staff morale is high resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. Positive recruitment practices and training arrangements are in place to make sure residents are not placed at risk and staff has the skills and abilities to meet the needs of residents. EVIDENCE: The records show that minimum staffing levels are maintained during waking hours and over night. Additional staff is on duty during peak hours of the day and waking night staff are employed each night. In addition a staff member sleeps at the home each night to assist with any emergencies that may occur. The providers have also established reliable on call arrangements in order that they can provide additional support when necessary. Residents commented they were very satisfied with the manner in which the staff meet their needs and provide the support they require. The residents said that staff were readily available, flexible and thorough in respect of all their duties and responsibilities. The residents have confidence in the staff and are complimentary about the quality of service they provide. Following the last inspection the providers have improved the recruitment, selection and vetting arrangements and this has resulted in robust arrangements that comply with the regulations and standards of good practise. St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 22 The staff at the home is well trained and are provided with regular opportunities to update their training and undertake new training opportunities. Six of the staff holds NVQ 2 and a further five have obtained NVQ 3. The providers have also established a training programme for 2006 that takes account of each staff members training needs. Therefore each staff member has a training plan for this year. The staff said there were no barriers to accessing training and they felt their needs were well catered for. St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 23 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): 33, 35, 37 and 38. The home is well managed and run by the providers for the benefit of the residents. The records at the home are generally good but some require improvement. This will make sure that residents needs are met and that residents or staff are not placed at risk. EVIDENCE: The providers have established a range of mechanisms to assess and review the quality of the services and facilities provided. The annual review for 2006 is planned for later in the year. In undertaking a review the providers consult with residents individually and as a group, residents or representatives of residents and professionals that have contact wit the home. St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 24 The last quality assurance assessment concluded there was a high level of satisfaction with the services and facilities provided. The providers will also assist residents to manage their personal allowances where required and there are no other suitable third parties to offer any help. Where assistance occurs the providers maintain robust records the detail each transaction. At the time of the inspection no residents were being assisted. The requirements set at the last inspection about records and the risk assessment and risk management arrangements at the home were considered. The records at the care home are in good order generally although certain records continue to require further improvement. This can be illustrated by the previous comments in this report about assessment and the administration of medication. The records are stored safely and accessible to the staff. The staff regularly uses the records available to assist them in their duties and to meet the needs of residents. There are no barriers to residents accessing their records if they wish. Daily records are kept for each resident. The records detail the events that have occurred; any incidents and any action the staff has taken. Some of the records also state the outcome of the action and could be improved by the staff providing more detailed information. The risk assessment arrangements and records have also improved following the last inspection. The records provide staff with more guidance, direction and information about the care and support required to minimise unreasonable risks. In certain instances additional information and guidance is required to make sure the staff and residents health and welfare is not compromised. The storage facilities at the home are not adequate and this could be a potential risk to residents. The providers are aware of this difficulty and are actively considering steps to provide additional storage space. St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 25 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 4 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X 2 2 St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 26 Are there any outstanding requirements from the last inspection? 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. 2. Standard OP2 OP9 Regulation 14(1) 13(2) Requirement Each prospective service user must be comprehensively assessed. The records about the administration of medication (MAR sheets) must be completed to the required standard. The policy and procedure for the protection of service users must be developed to reflect the Department of Health Guidelines ‘No Secrets’. The floors on the first floor must be replaced or repaired to make sure that service users are not placed at risk. Sluice facilities must be provided. The records at the care home must comply with the Care Homes regulations 2001. Sufficient storage space must be provided at the home. The records about managing risk at the home must detail the events that have occurred, the assessment of risk and any action required by the staff to
DS0000041642.V272947.R01.S.doc Timescale for action 30/04/06 30/04/06 3. OP18 13(6) 30/06/06 4. OP19 13 30/01/07 5. 6. 7. 8. OP26 OP37 OP38 OP38 13 17 13 13 30/01/07 30/05/06 30/01/07 30/06/06 St Clair House Care Home Version 5.0 Page 27 minimise risks in the future. 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 OP37 Good Practice Recommendations Service users daily records should state the outcome of any action that staff has undertaken. St Clair House Care Home DS0000041642.V272947.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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