Inspection on 02/12/08 for St Erme

This inspection was carried out on 2nd December 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Erme 24/11/09

St Erme 08/07/08

St Erme 12/12/07

St Erme 14/08/07

St Erme 07/03/07

St Erme 24/07/06

St Erme 16/02/06

St Erme 27/09/05

St Erme 11/11/04

St Erme 27/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

CARE HOME ADULTS 18-65 St Erme Trispen Truro Cornwall TR4 9BW Lead Inspector Ian Wright (with Michael Dennis) 2 and 4 nd th Unannounced Inspection December 2008 09:00 St Erme DS0000009149.V373396.R01.S.doc Version 5.2 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 Erme DS0000009149.V373396.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 Adults 18-65. 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 Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Erme Address Trispen Truro Cornwall TR4 9BW 01872 263355 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) Mail@dcact.org Spectrum Manager post vacant Care Home 20 Category(ies) of Learning disability (20) registration, with number of places St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. St Erme House - up to 10 adults with a Learning Disability (LD) The Lodge - up to 9 adults with a Learning Disability (LD) St Michaels - up to 3 adults with a Learning Disability (LD) Total number of service users not to exceed a maximum of 20 Date of last inspection 8th July 2008 Brief Description of the Service: St. Erme is a care home providing accommodation and personal care for up to 20 adults with a learning disability. The registered provider is Spectrum, which manages a number of homes providing care for people with autism. The service comprises of three separate, self-contained units: • St. Erme House provides accommodation currently for up to five adults. People have their own bedrooms, some of which are en suite and their own lounge. There is also a communal lounge, dining area and kitchen. There is a secure garden. There is a self contained flat, for one person, attached to the house. • The Lodge currently accommodates four people. People have their own bedrooms. There are shared bathroom, lounge, dining, and kitchen facilities. There is a garden. • St. Michaels can accommodate up to three people. People have their own bedroom, and share lounge, dining, and kitchen and bathroom facilities. One of the people accommodated has their own self-contained ‘flat’ within the home. There is a separate administrative block on the site. St Erme is set in its own extensive grounds, in the village of Trispen, which is close to the city of Truro. Current fees range from £930 per week to £4266. There are variable additional charges to individuals for personal items such as hairdressing, newspapers, confectionery, private chiropody and off-site entertainment. St Erme DS0000009149.V373396.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 one star. This means the people who use this service experience adequate quality outcomes. Two inspectors completed this key inspection in twelve hours over two days. All of the key standards were inspected. The methodology used for this inspection was: • To case track three people who use the service. This included, where possible, meeting and discussing with them their experiences, and inspecting their records. • Discussing with staff their experiences working in the home. • Discussion with other people who use the service and their representatives. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), was used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? The registered provider has ensured there has been significant improvement to the management of medication, although there is some work still required. An operational management team are in place and they appear competent. Care planning now is to a good standard. St Erme DS0000009149.V373396.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessment information obtained about people who use the service prior to admission, and information issued to people when they move in is good. This helps to ensure people’s needs are met, and suitable information is issued regarding people’s rights and responsibilities. EVIDENCE: Copies of contracts of care / statement of terms of conditions of residency were present on the files of people we case tracked. Copies of pre admission assessments were also inspected and these were comprehensive. A copy of the registered provider’s assessment policy was also inspected and this is satisfactory. St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home appear to have their individual needs and choices met so they should be able to live a life style according to their wishes and needs. EVIDENCE: Each person has a care plan, and there is evidence these are reviewed appropriately. People who use the service seem to be encouraged to make decisions regarding their lives where possible. Suitable risk assessments are in place to assess any risks or actions to promote independence. The registered provider looks after some people’s monies, for which suitable records are maintained. There was a small error regarding one person’s money (i.e. there was more money than was accounted for) so extra care needs to be taken by staff to avoid this occurring. The registered provider acts St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 10 as an agent for financial benefits / saving accounts for some people’s monies, for which suitable records are kept. Personnel at Spectrum headquarters manage government benefits claimed on behalf of people who use the service. There should be a schedule of what benefits (and the weekly amount claimed) in each person’s file. St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable opportunities for activities, educational opportunities and contact with the wider community are provided so people have the opportunity to live a varied lifestyle. Food provided appears to be to a good standard. EVIDENCE: According to care plans and daily records, people who use the service have a suitable range of activities available to them, and that they participate in. The registered provider has several minibuses available to people living in the home. These enable people to move around the community and to go out on social trips. People who use the service can visit friends and relatives, and can also maintain contact via the telephone or post. Visiting arrangements are flexible, and there is suitable space for people to receive visitors privately. St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 12 Times when people get up and go to bed are flexible, although there does need to be some fixed routines due to the nature of people’s diagnosis. We observed staff working in a manner, which was professional, and respected the privacy and dignity of people who use the service. Food provided appears to be to a good standard and suitable records are maintained regarding food provided. People who use the service have access to the kitchen, with varying degrees of staff support according to people’s needs. There are suitable laundry facilities. People using the service are encouraged to participate in doing their laundry with varying degrees of staff support. St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is generally good. This judgement has been made using available evidence including a visit to this service. Personal and health care support is delivered to a good standard, and there are suitable links with medical professionals. The management of medication has significantly improved although some further work is required to bring practice up to the national minimum standard. People who use the service, and their representatives, therefore should be able to be assured personal and health care needs are suitably met. EVIDENCE: People who use the service said they receive suitable care and support from staff. Any personal care needs are clearly documented in care plans, and staff seem clear regarding what assistance people require. Care plans document appropriate links with GP’s, dentists, chiropodists and other professionals. People who use the service said they regularly saw medical professionals when required. The operation of the medication system is generally satisfactory. Medication is generally stored securely. Medication is dispensed via a ‘monitored dosage system’. Medication records kept are generally appropriate. There is a suitable St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 14 medication returns system. Staff have received suitable training regarding the handling of medication. However the following improvements are required: • If people are prescribed medication which is not printed on the medication administration record, any handwritten entries need to be double signed by two members of staff. • Controlled drugs have recently been prescribed for one person. A controlled drugs cabinet is on order. We gave the manager guidance how entries need to be recorded in the controlled drugs book. It would be a good idea to ensure this issue is addressed in the Spectrum training. • Where medication is not administered it is essential a reason is given. For example a code is used (as outlined on the administration record sheet), and the reason recorded on the back of the medication sheet. • If PRN ‘as required’ medication is given regularly, staff should liaise with the GP to ascertain whether the medication should be administered on a regular basis, rather than as PRN. • If PRN medication is not administered, staff should liaise with the GP to ascertain whether it is no longer required. Apart from these matters we were happy with the significant improvement that has occurred regarding the operation of the medication system. St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is generally good. This judgement has been made using available evidence including a visit to this service. There are suitable complaints and adult safeguarding procedures in place. Subsequently people who use the service, and their representatives can be assured there are appropriate procedures to deal with any concerns or bad practice. EVIDENCE: The registered provider has suitable complaints and adult safeguarding procedures. There have been no complaints received by the registered provider or the Commission for Social Care Inspection. There is one outstanding adult safeguarding issue which will be reviewed in the New Year. The majority of staff have also attended training regarding the prevention of abuse. Staff and people who use the service all said they had not witnessed any bad or abusive practices. All staff have Criminal Record Bureau check, and a Protection of Vulnerable Adults check (where applicable). St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. St Erme generally provides a suitable environment for people using the service, although some further improvement is required to the décor and fabric of some areas of the site. EVIDENCE: We inspected the three units on the St Erme campus. St Michaels. The accommodation is generally satisfactory. Some aspects of the accommodation are rather utilitarian, but this is due to the needs of the people in the home. One of the Spectrum director’s said to us that due to the behaviour of people, fixtures and fittings had to be tailored to people’s needs to prevent harm and damage. However, as people’s skills developed more homely fixtures and fittings would replace the current provision. The manager of the unit said staff would be purchasing more fixtures and fittings to help create a more homely atmosphere. She also said the decorators would visit in the next week to improve the standard of décor. One person has their own self-contained ‘apartment’ within the unit, which seems pleasant. St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 17 The sleep in facility is very basic (a futon /mattress is placed on the floor of one of the offices at night). These should be improved if possible so staff are more comfortable. The building however was clean and appeared safe. The Lodge The accommodation is generally satisfactory. Some aspects of the accommodation are rather utilitarian, for similar reasons to St Michaels. The downstairs of the building was generally satisfactory although staff should continue to work, where possible, to make the environment as homely as possible. Some of the upstairs facilities need improvement. For example: • Floor coverings in some areas should be replaced to improve the ambiance of the building. For example in one area of the corridor the floor appears to be a painted rough surface . • One of the shower trays used by people using the service had some visible mould which needs attention. • One person’s bedroom smelt slightly of urine. This is due to behavioural issues. However, the odour may be less if the wood effect flooring is replaced with an impermeable surface. • Some of the individual lounges and other rooms upstairs, did not have a storage heater. It is essential that each room used by staff and/ or people using the service have satisfactory heating. The House. This part of the service has been extensively refurbished and, from what we inspected, seemed to a high standard. One person has a flat, in part of the building. This appears suitable for the person. Spectrum plan to develop this facility to have its own kitchen. The organisation should liaise with our registration department regarding this as necessary. Some rugs in different areas of the building were curling at the corners. This could present a trip hazard. It is important suitable material is purchased from a hardware or carpet store to stick under the rugs to prevent this. St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels, recruitment checks and staff training appear to be to a suitable standard. This should help to ensure people who use the service receive appropriate staff support from suitably recruited and trained staff. EVIDENCE: From our observation people who use the service seem to receive professional and caring support from staff. The people who use the service can display behaviour which could be deemed difficult and challenging. Staff seem to support people in a positive manner. Staff we spoke to were generally positive about the service and the support they receive. Some people have commented they would appreciate a higher presence from management, and the number of changes in management personnel can at times be not beneficial. We appreciate some of these matters are unavoidable, and it is a difficult task to balance management responsibilities, with being always available to support staff. However the concerns should be acknowledged and management should do what it can to minimise the concerns. St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 19 There were satisfactory numbers of staff on duty on the days of the inspection in each part of the service. We checked staff recruitment records and these are maintained to a high standard. There is suitable evidence all staff receive a Protection of Vulnerable Adults ‘First’ check, a Criminal Records Bureau check, two written references etc. Staff training is to a good standard. The registered provider has a suitable approach to providing National Vocational Qualifications (NVQ). The minimum training we would expect to be delivered to all staff in this service is: • • • • • • • • • • Fire training-at least annually. Food hygiene / handling training- if staff handle food. First Aid training- in line with CSCI and HSE guidance for example at least a satisfactory number of staff on duty at all times trained to ‘appointed persons’ level. Manual handling training- in line with moving and handling regulations and the needs of people living in the home. Training regarding medication-if medication is handled. Infection control. Basic training regarding hand washing, use of protective clothing etc. Awareness of people on the Autistic Spectrum Training regarding handling aggressive behaviour including restraint techniques (if the latter is appropriate). Epilepsy-if people accommodated have this diagnosis. Record of induction when the person starts working at the service (e.g. orientation, how to work with individuals in the home, awareness of policies and procedures etc. Suitable induction records were available for all staff. Spectrum ensures new staff are shadowed when they commence work alongside more experienced staff. Staff also complete a five day formal induction at the organisation’s training centre where most of the training required is delivered. Staff then receive follow up and more detailed training according to the needs of people accommodated in the service. Training records for the staff records assessed seemed comprehensive. A staff supervision system is in place. We did not assess records of this. It is important that ‘bank’ staff also have access to regular supervision. St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. Management arrangements are improving, although it is essential that the registered provider submit an application for registered manager(s) for the service as a priority. Improvement is also required to health and safety precautions. These measures will help to ensure management arrangements improve, and there is a higher level of safety precautions at the service. EVIDENCE: Spectrum has reviewed the management arrangements at St Erme. The registered provider has said to us they intend to split the service into two registered services: • St Erme House- with one registered manager. • The Lodge and St Michaels-with one registered manager, with a separate manager for St Michaels who will be overseen by the manager at The Lodge. Under the current management arrangements, we are concerned there has not been a registered manager at this service for some time. The current St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 21 certificate displayed was issued by the National Care Standards Commission on 23/6/2003. The NCSC was superseded by CSCI in April 2004, and the named manager has not been in post since 2006. There have been a number of changes since then. This obviously can be unsettling for people using the service, their representatives and the staff group. We appreciate St Erme must be a difficult service to manage, and the proposed changes to the management structure should be beneficial. We also appreciate it is essential to find the right personnel to manage such a service. However such gaps in there being a registered manager are not satisfactory and need to be avoided. We are repeating the previous requirement for the submission of a registered manager’s application. If there is failure on behalf of the registered provider to submit an application(s), we could take enforcement action. The current management team appear to be positive, professional and organised. We were encouraged by their approach and openness. Some staff said they would like to see some of the manager’s more, and felt there should be a higher management presence in the service. As stated earlier in the report it is a difficult balance to carry out management tasks, be supportive to staff, and do some ‘hands on’ work all within full time equivalent hours. It is also important that managers delegate tasks and responsibilities to other managers, and the staff group in general, in order to create team ownership and responsibility. However management should note the comments made, and do what they can regarding what can be a difficult ‘balancing act’. There is a suitable approach to quality assurance. Surveys to ascertain the views of stakeholders involved in the service were completed in 2008. One of the managers’s said she was using the feedback as a tool to bring about service improvement. This is a good use of the material obtained. A representative of the registered provider carries out monthly visits (in line with regulation 26 of the Care Homes Regulations 2001). The reports of these visits are comprehensive. The managers of each unit have completed an annual development plan and these are good. There are some staff meetings in each of the units. We recommend the frequency of these in The Lodge and The House be increased. However, we do understand it is logistically difficult to arrange these due to the numbers of staff employed, and the need of people living in the homes to have staff working with them who have a deep understanding of their needs. Management could try to have several ‘group’ staff meetings so all staff can attend e.g. over a period of a week. Group supervision can also be a useful model. Both approaches can improve staff consistency, consultation and support. St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 22 The registered provider has a suitable health and safety policy. Records kept of health and safety checks are in some cases satisfactory. For example there are suitable records of the testing of fire equipment and portable electrical appliances. However, the registered provider needs to ensure there is a certificate to state the electrical hardwire circuit in The House has been tested and is safe. There is a note to state this work was completed, but the certificate has gone missing. A duplicate needs to be obtained and a copy needs to be forwarded to the Commission. There are satisfactory records that the hardwire circuits have been tested in the other parts of the service. The registered provider needs to ensure there is evidence gas and/ or oil fuelled appliances and /or heating in The Lodge and The House has been serviced and is safe. Copies of relevant certificates need to be forwarded to the Commission. There are satisfactory records regarding these tests in relation to St Michaels. Accident and incident records are suitably maintained. Health and safety risk assessments are satisfactory. There needs to be records regarding any testing completed regarding the prevention of Legionella. The Environmental Health Department can provide advice regarding this. The Health and Safety Executive also publishes information regarding this. This information is on their website. Suitable insurance cover for the buildings was available for inspection. St Erme DS0000009149.V373396.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 Adults 18-65 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 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 2 X 3 X X 2 X St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 24 YES 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. Standard YA20 Regulation 13(2) Requirement The registered provider must make improvement to the operation of the medication system. Matters outlined in the body text of the report need to be addressed. This will give people who use the service, and their representatives, further reassurance that medication is managed to a good standard. The registered provider needs to continue to make improvements to the décor and fabric of the building. Where possible, the matters outlined in the body of the report need to be addressed. This will ensure there is further improvement to the accommodation provided for the people who use the service. An application for registered manager(s) must be submitted to CSCI. (Previous deadline of 25/09/08 not met Third Notification) The registered provider must ensure there are satisfactory health and safety precautions at DS0000009149.V373396.R01.S.doc Timescale for action 01/01/09 2. YA24 16,23 01/06/09 3. YA37 8,9 01/03/09 4. YA38 13 01/03/09 St Erme Version 5.2 Page 25 the service. For example: • A certificate to state the electrical hardwire circuit has been tested and is safe. A copy of the certificate in regard to needs to be forwarded to the Commission. • There is evidence gas and oil fuelled appliances and /or heating in The Lodge and The House have been tested and are safe. Copies of relevant certificates need to be forwarded to the Commission. • Evidence suitable precautions are taken regarding the prevention of legionella. 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 OP31 OP35 Good Practice Recommendations Increase the frequency of staff meetings which occur at The Lodge and The House There should be a schedule of what financial benefits (and the weekly amount claimed) in each person’s file. St Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Erme DS0000009149.V373396.R01.S.doc Version 5.2 Page 27 - 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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