Inspection on 20/03/06 for St Faith`s Nursing Home

This inspection was carried out on 20th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 Faith`s Nursing Home 31/07/06

St Faith`s Nursing Home 24/10/05

St Faith`s Nursing Home 01/03/05

St Faith`s Nursing Home 23/09/04

St Faith`s Nursing Home 12/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE St Faith`s Nursing Home Malvern Road Cheltenham Glos GL50 2NR Lead Inspector Malcolm Kippax Unannounced Inspection 20th March 2006 09:15 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 Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Faith`s Nursing Home Address Malvern Road Cheltenham Glos GL50 2NR 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) 01242 240240 01242 224353 Cheltenham Old People`s Housing Society Limited (The Lilian Faithfull Homes) Mrs Patricia Anne McCluskey Care Home 69 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (69) of places St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 Service User under 65 Years. Date of last inspection 24th October 2005 Brief Description of the Service: St Faith’s Nursing Home is a large attractive property, which has been extended and refurbished to provide comfortable accommodation for 69 elderly service users who require nursing care. The home is owned and managed by a charitable organisation and is one of the Lilian Faithfull Homes. It is situated in a residential area, close to the centre of Cheltenham and to local amenities. Service users are accommodated in two wings of the Home. Twenty-seven Residents are cared for in the Fairhaven Wing, which compromises three Floors and two mezzanine levels. Northcroft wing accommodates forty-two residents on three floors. All of the service users have the benefit of a number of accessible sitting rooms and dining areas throughout the building. There is also a well-equipped multi sensory room where aromatherapy and reflexology treatments may be given. The Home has a day care facility to care for people with Dementia. The service users have the benefit of a landscaped garden, which is easily accessible. St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place from 9.15 am - 6.05 pm and it focussed on some key standards that were not covered at the last inspection. Requirements and recommendations from the previous inspection were also followed up. The outcome for service users was looked at through observations and discussions in a lounge and in a dining room during lunch. Three service users were also spoken with in their own rooms. There were meetings with the registered manager, six members of the staff and management team and with four relatives. Some of the home’s records were looked at including care plans, daily reports, activity logs, menus and quality assurance. What the service does well: What has improved since the last inspection? What they could do better: The home’s recruitment procedure needs to be looked at further to ensure that there is no risk of unsuitable staff being appointed. Questionnaires given out from the home have produced a good range of feedback about the outcomes of the service provided. To make the most of this feedback it should be included within a system for quality assurance and annual development. St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 6 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 Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not looked at on this occasion. (Standard 3 was met at the last inspection). EVIDENCE: St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 9 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): These standards were not looked at on this occasion, other than to follow up requirements from the previous inspection. These have not been fully met. (Standards 8 and 10 were met at the last inspection and requirements were identified in respect of standards 7 and 9). EVIDENCE: Requirements had been made at the last inspection about the need, where applicable, to record information in the care plans about bedrails and bumpers, continence, and any additional action that is implemented. These requirements were followed up by looking at examples of care plans in the ‘Fairhaven’ wing of the home. References to bedrails, such as ‘in situ for safety’ were recorded in the plans. There was no risk assessment for their use. Details of the type of continence aids used by one service user were recorded on an appropriate form, although the changes during the day were being recorded on a ‘fluid balance’ chart under the column headed, ‘other types of feed’. One service user’s care records included a core care plan form that had been completed in respect of a skin tear. Some entries had been recorded in St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 10 February about the condition of this. The last entry referred to the wound being redressed and further information was needed about whether the wound had now healed or was still receiving attention. It was recommended at the last inspection that care plans should be reviewed on a monthly basis. The dates of reviews are recorded on a care plan review form. The forms seen showed that reviews had taken place in February 2006. Some reviews may not be taking place monthly as it was stated that ‘All care plans to be reviewed as required or three monthly – Social Services must be reviewed and recorded monthly’. Risk assessments were seen on the service users’ care records in areas such as falls, moving & handling and pressure sore prevention. These had last been reviewed during the previous month. The covert administration of medication was discussed with Patricia McCluskey. The policy on this has been reviewed since the last inspection and further guidance is available about the administration of medication to people with swallowing difficulties or feeding tubes. Patricia McCluskey said that nobody was currently receive medication covertly and confirmed that approval would be obtained from the GP before this happened. Patricia McCluskey said that stock rotation of medication was now being checked on a regular basis, as recommended at the last inspection. St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 11 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, 13, 14 and 15 Service users benefit from the home’s approach to visiting, mealtimes and the provision of activities. EVIDENCE: Some service users were spending time in their own rooms and others were using the lounges. The home employs activities assistants to support service users and four staff members were deployed in this role at the time of the inspection. During the afternoon there were two group activities taking place. One of these was a word and board game activity involving eight service users who were supported by two staff. Some service users were active participants and others were taking an interest without directly contributing. The social aspect of the activity was helped when there was a break for a cup of tea and a piece of cake. It was seen that some additional facilities would assist service users who had no convenient place to put their cups. One of the service users met with was watching television in his own room. He said that he was aware of the activities taking place and might have joined in if there was not sport to watch on the television at the time. He also said that he enjoyed the meals. There was a planned daily activity programme, with certain times identified as individual sessions for ‘residents who are unable to join one of the groups’. St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 12 The staff members spoken with said that they gave these individual sessions a high priority. It was the aim for each service use to have a minimum of two sessions a week, although resources did not always make this possible. The planned programme showed a range of events and activities taking place during the week, including church worship, excursions and tea dances. Activities using a multi-sensory room within the home are also identified. The service users’ records contained a ‘Residents Profile’, which gave background information in areas such as ‘pets’, ‘favourite things’ and ‘interests’. ‘Activities forms’ are used for the recording of the individual sessions that have taken place. Sessions had included ‘individual chats’ and time spent in the multi-sensory room. Of the two examples seen, one service user had so far had eight sessions during March and another had two. One of the relatives met with said that the quality of the activities being provided had improved. All the relatives spoke very positively about their experience of the home. They were happy with the visiting arrangements and made to feel welcome. The relatives had been able to help service users with personalising their rooms. Care records are kept in the rooms. The service users’ names are clearly identified outside their rooms and the bedroom doors have been painted in a variety of colours, which helps them to stand out. There is a policy on advocacy and leaflets are available about local services. Patricia McCluskey felt that that none of the current service users were in need of an advocacy service. Meals are prepared by outside caterers in the home’s own kitchen. There is a four-week menu, with a choice of courses available each day, including vegetarian. Patricia McCluskey said that she met with the caterers each month to discuss the service provided. All special diets are reported to be available if needed. The home has gained a ‘Spa Award’ from the local environmental health department. Service users eat in a number of different dining areas. There is a second sitting for lunch in one of the dining rooms and this was observed during the inspection. There were four service users eating at the time, supported by three staff members. Some staff members are specifically deployed to assist service users at lunchtime. Two service users were receiving one to one support with their meals, the contents of which had been separately pureed. Although the service users were not conversing, it was noticeable that staff members were talking to service users and taking time to describe the contents of the meal. One staff member said that it was important to do this because she knew that a familiar voice was reassuring and helped the particular service user she was with. Staff members confirmed that arrangements that are in place for the checking of temperatures and for the recording of fluid and food intake. St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 13 It was noted from one service user’s care notes that she receives a ‘peg feed’ in her own room. This was looked at further and there was an up to date record in place which showed the timing of the feed and that the regime was being kept under review. A social occasion is arranged once a month, which includes the serving of an evening meal in surroundings with a particular theme, such as ‘Italian Night’. The home had received good feedback about these occasions from the relatives and others who are invited to share the occasion with service users. In one letter of thanks the comment was made that they ‘celebrate the strengths and diversity of people who experience dementia’ St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Formal complaints are not being made. The service user’s representatives have received the information they need and feel that they will be listened to. There are procedures in place which help to ensure that service user are protected. EVIDENCE: Patricia McCluskey said that there was a file for the recording of complaints, but none had been received. A complaints procedure is included in the service user’s guide. Many of the service users would need assistance with making a complaint. The relatives met with said that they knew whom to contact if they had any concerns and felt confident about how these would be followed up. Policies have been produced on abuse, whistle blowing and the protection of vulnerable adults. Two members of the care staff met with said that they had received training in the area of abuse and POVA. They were aware of the home’s policies, but could not recall seeing a copy of the ‘No Secrets’ booklet. Staff training was discussed with the organisation’s Training & Development Officer. A training programme for staff has been produced. The T & D Officer had attended an ‘Action on Elder Abuse’ course and a further course was shortly to be attended. St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 15 Patricia McCluskey said that no referrals had been made under the Protection of Vulnerable Adults procedure during the last year. The manager expressed confidence about what to do and confirmed who would be contacted if a referral was needed. The home has not needed to have contact with the local vulnerable adults unit. A police officer from the unit may be available to talk to staff about their work. This could be a useful addition to the training and guidance that the staff team already receive. St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not looked at on this occasion. (Standard 26 was met at the last inspection and standard 19 was exceeded). EVIDENCE: St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 17 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 and 28 Staff members have well defined roles and service users benefit from the deployment and mix of the staff members on duty. Difficulties in the provision of N.V.Q. have meant that levels of qualification within the staff team are less than expected. Arrangements have been made to address this. The recruitment arrangements may not prevent unsuitable staff from being appointed. (Standard 30 was met at the last inspection and requirements were identified in respect of standard 29). EVIDENCE: Standard 27 was exceeded when last inspected and there have been no changes affecting the deployment of care staff since that time. Patricia McCluskey said that there were now more activities and domestic staff being employed and that dependency levels had reduced during the last year. The staff rota was looked at. At the time of the inspection the deployment of staff included three nurses, two ‘adaptation’ nurses, a mental health advisor, and 14 carers, two of whom had just finished their induction. Other staff were covering domestic work, activities and reception duties. St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 18 Patricia McCluskey said that the home did not need to use agency carers. Relatives were complimentary in their comments about how staff went about their work. One person said that they got to know particular staff members (‘nominated carers’) very well. There were reported to be 8.8 of care staff with NVQ when this was last looked at in September 2004. The organisation’s HR and Development Manager said that they had since experienced a problem with their NVQ provider, which meant that ‘only a handful of carers’ had achieved their NVQ. The exact number of care staff could not be confirmed. New arrangements have been made for the provision of NVQ and it was anticipated that the number of qualified staff would now increase over time. A training audit was briefly discussed, as a way of having an up to date record of staff members’ qualifications and the training events that they have attended. It was reported at the last inspection that some staff had been recruited without all of the required checks having being undertaken. Requirements had been made in connection with this. The present arrangements were discussed with the HR and Development Manager. Newly appointed staff bring the required documentation with them on their first day, when the CRB and a POVA first check is applied for. A record is kept of when these checks have been applied for and completed. Carers continue to be appointed before the outcome of their POVA and CRB check is known although they are reported not to be working unsupervised while these checks are being undertaken. The Chief Executive Officer from Lillian Faithfull Homes was met with at the end of the inspection and he said that the procedure in relation to POVA checks would be discussed further with the management team. The HR and Development Manager said that a decision to employ a person with criminal convictions would be based on a risk assessment, as discussed at the previous inspection. This situation was reported not to have arisen since the last inspection. It was recommended at the last inspection that the home reviews its practice of storing criminal records bureau disclosures with regard to the requirement for inspection by the Commission. It was agreed that it would be useful to discuss this further with the inspector for the home in order to agree expectations and responsibilities in this area. St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 19 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): 31, 33 and 35 Service users benefit from the registered manager’s experience and from continuity in the running of the home. There are recognised systems in place for quality assurance within the organisation. The home has received good feedback about the outcomes for service users. Service users would benefit from including this within a system for quality assurance and annual development. (Standard 36 was almost met at the last inspection and a requirement was identified in respect of standard 38). EVIDENCE: Standard 31 was exceeded when last inspected and there have been no changes affecting the management of the home since that time. Patricia McCluskey has been the registered manager at St. Faith’s for over five years and has also had experience as manager of another care home. St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 20 Patricia McCluskey is qualified as a first level mental health nurse and general nurse. Patricia McCluskey spoke about some courses that she had attended during the last year, which covered the subjects of palliative care, dementia care and the use of syringe drivers. A monthly meeting is held involving managers from the Lillian Faithfull homes. Several people spoken with during the inspection were complimentary about the running of the home and the atmosphere. A recommendation was made at the last inspection that the home should demonstrate that care staff receive six supervision sessions per year. The arrangements for supervision were discussed with Patricia McCluskey, who said that staff members receive regular supervision but the records would be unlikely to show that each staff member had received a minimum of six sessions within a twelve-month period. However, Patricia McCluskey felt that this frequency of supervision would be evident if staff meetings are included. It may be appropriate to include these as part of the overall supervision arrangements, if an element of group supervision can be demonstrated. Patricia McCluskey said that the registered provider has received ‘Investors in People’ accreditation and continues to use the ISO 9001 quality assurance system, which involves a monthly internal audit and an annual external verification. Questionnaires have been distributed to various parties, mainly relatives. Two different types were seen, one a ‘How was the admission?’ questionnaire, and another one, ‘How are we performing?’, that is given out later. The first one looked better, because it gave the respondents the opportunity to comment on the outcome, rather than being a tick box format. It would be useful to develop the second questionnaire. Some useful comments had been received. Patricia McCluskey said that these were followed up but the feedback did not contribute to an annual development or improvement type plan for the home. There is a business plan for the home. The relatives met with were open in their comments about the home. Their views about the home were very positive. All service users entering the home are required to have power of attorney in place and that the home had no involvement in the management of the service users’ financial affairs. An exception to this concerned the Chief Executive Officer who is in the role of appointee to two service users. He said that this arrangement was well established and had been in place for a number of years. Financial records kept by the home were not looked at on this occasion. St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 21 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 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 3 X X X X X X X X STAFFING Standard No Score 27 4 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X X St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 22 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 (2) (c) Requirement Timescale for action 30/04/06 2. OP7 15 (1) 3. OP29 19 (1) (b)Sch 2 The registered person must ensure that where there is additional action implemented that is not documented on the pre-printed core care plan this must be added. (Met in part since the last inspection. Further information is needed about the action that has been taken). 30/04/06 The registered person must ensure that where continence aids are used or continence routines are implemented the type and size of pads used and the toileting routine is recorded in the care plan actions on the core care plans. (Met in part since the last inspection. Changes in pad need to be recorded on an appropriate form). The registered person must not 30/04/06 employ a person to work at the care home unless he has obtained the information and documents specified in paragraphs 1 to 9 of Schedule 2. (Outstanding from the last inspection). DS0000016584.V285722.R01.S.doc Version 5.1 St Faith`s Nursing Home Page 23 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 OP7 OP7 Good Practice Recommendations That individual risk assessments are undertaken concerning the use of bed rails and bumpers. Care plans should be reviewed on a monthly basis. (Outstanding from the last inspection – the guidance about the frequency of reviews should be amended to ensure that all care plans are reviewed on a monthly basis). That the local vulnerable adults unit is contacted to see whether a police officer from the unit is available to talk to staff in the home. That a check is made of the availability of coffee tables and similar facilities to ensure that service users have a convenient and safe place to leave their cups and plates. That an audit is undertaken in order to obtain an accurate and up to date record of the qualifications that staff have gained and the training they have received. The home should review its practice of storing criminal records bureau disclosures with regard to the requirement for inspection by the Commission. (To be discussed further with the inspector for the home in order to agree expectations and responsibilities in this area). That the arrangements for obtaining feedback from service users are included within the home’s system for quality assurance. A plan or policy for quality assurance should show how the service users’ views are contributing to annual development and improvement in the home. The home should demonstrate that care staff receive six supervision sessions per year. (Outstanding from the last inspection). 3. 4. 5. 6. OP18 OP20 OP28 OP29 7. OP33 8. OP36 St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Faith`s Nursing Home DS0000016584.V285722.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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