Inspection on 29/09/05 for St Judes

This inspection was carried out on 29th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Judes 17/04/08

St Judes 23/10/07

St Judes 01/05/07

St Judes 14/02/07

St Judes 18/05/06

St Judes 02/02/06

St Judes 10/05/05

St Judes 21/10/04

St Judes 17/06/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE St Judes 89 Cardigan Road Bridlington East Yorkshire YO15 3JU Lead Inspector Diane Wilkinson Announced Inspection 29th September 2005 09:30 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 Judes DS0000019726.V253676.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 Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Judes Address 89 Cardigan Road Bridlington East Yorkshire YO15 3JU 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) 01262 674129 Mrs Patricia Elizabeth Lewis Mrs Patricia Elizabeth Lewis Care Home 14 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (14) of places St Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2005 Brief Description of the Service: St Judes is a privately owned care home that is registered to provide care and accommodation for fourteen service users (male and female) who are over 65 years of age, including those with dementia. Accommodation at the home is provided in single and shared rooms, with en-suite facilities in three of the nine bedrooms. In addition to private accommodation, there is a lounge/dining room, a lounge and a small smokers lounge. There is a garden at the rear of the property, which is safe and secure. Most areas of the home are accessible via the provision of a passenger lift and ramps, but the second floor is only accessible via the use of stairs. St Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by one inspector over a period of nine hours, including preparation time prior to the inspection. The inspection included a tour of the premises and examination of documentation, including care plans. The inspector spoke to two service users (one to one), a staff member, the manager and the registered provider during the course of the inspection. Pre-inspection information was not sent to the inspector so questionnaires could not be sent out to GP’s and other health professionals. Service user and relative/visitor questionnaires were sent to the home to distribute – only one questionnaire was returned from a visitor and the response about the care provided by the home was positive. What the service does well: What has improved since the last inspection? Staff training has taken place resulting in staff being better equipped to care for the service users accommodated – this includes induction training for new staff. There is now a training and development plan in place, in addition to individual training records. The staff rota is now an accurate reflection of the actual staff that are on duty. There is now a complaints log in place. Staff meetings are held and minutes are recorded – these evidence that staff are able to freely discuss concerns and suggestions. Policies and procedures produced by the home are now discussed at each staff meeting. Formal staff supervision has commenced at the home – this system needs to be expanded to ensure that all care staff have supervision six times per year. St Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Judes DS0000019726.V253676.R01.S.doc Version 5.0 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 Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 The lack of a full assessment of needs prior to admission could result in a service user’s current care needs not being met by the home. Staff training and experience indicate that the current needs of service users can be met. EVIDENCE: There is an admission procedure and an emergency admission procedure in place. No service users have been admitted since the last inspection, but admission details were examined for the most recently admitted service user. Although the inspector was informed that the service user’s relative visited the home as part of the admission process, records do not evidence this, and there are no details of an initial assessment in records. The service user is privately funded and care management were not involved in the admission, so no assessment was available from them. It is not confirmed with service users at the time of admission that their current care needs can be met by the home. Staff have discussed the protection of vulnerable adults from abuse and caring for people with Alzheimer’s at staff meetings, and are due to have training on St Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 9 dementia care. They are now more equipped to meet the needs of current and prospective service users. Training records evidence that new staff now undertake appropriate induction training. Current records do not fully demonstrate that all specialised services offered are based on current good practice guidelines. St Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Service users need to be more involved in the care planning process to ensure that their wishes are recorded. Care plans evidence that the health, personal and social care needs of service users are met. The systems for the administration of medication are good but staff must undertake accredited training to ensure that the health and safety of service users is protected. Service users report that privacy and dignity is respected at all times. EVIDENCE: Care planning at the home has improved - monthly reviews of the care plan are recorded and formal reviews are taking place by care management service users attend formal reviews whenever this is possible. Reviews must also be held for those service users who are self funding. There are risk assessments in place, and these include a person’s risk of falling. There is insufficient evidence that service users or their representatives are involved in the care planning process. A new ‘client detail’ form has been developed but those seen in records by the inspector were blank. Some monthly summaries were not dated so it was not possible to check if these are recorded every month. St Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 11 There is evidence that a service user’s health care needs are met. There is a pressure care policy in place, and any risk of a service user developing pressure sores is recorded and suitable equipment is provided. Nutritional screening takes place – fluid and food intake is recorded in daily records, and weight is recorded via the daily living profile. A record is kept of visits from GP’s and other health professionals. All service users have an aromatherapy session once weekly (unless they request otherwise) and a manicure and hand massage once monthly – service users do appear to enjoy and benefit from these alternative therapies. Continence care provided by the home is appropriate. There is a new policy in place for the administration of medication – this needs to be further improved to include details about the administration of controlled drugs. A pharmacist visited the home at the beginning of September to undertake an annual review – records evidence that the pharmacist was satisfied with the systems in place. Whilst at the home the pharmacist provided a brief training session for staff on the safe handling of medicines. The inspector examined medication administration records and found these to be satisfactory – there is a list of staff that are ‘approved’ to administer medications and there is a photograph on records for each service user. Staff are awaiting accredited training to ensure that they have the knowledge to administer medication safety – this training is booked with a local training provider. New staff at the home now undertake Induction training that meets Skills for Care specifications. Following induction, staff have a three-monthly review when their understanding of induction training is checked. Staff meetings now take place on a regular basis and three of the home’s policies and procedures are discussed at each meeting to reinforce staff’s understanding. Service users spoken to on the day of the inspection said that they are treated with dignity and respect. There is a death and dying policy and a palliative care policy in place at the home. These are stored in the ‘staff area’ and are due to be discussed at the next staff meeting to ensure that staff understand and follow the policies and procedures that are in place. A service user’s ‘wishes for the future’ are recorded in care plans. St Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 14 Friends and relatives are encouraged to visit the home and to take service users out. Service users are supported to make choices about their lives within their capabilities. EVIDENCE: Standard 15 was not assessed on this occasion as it was met at the last inspection but the inspector did observe that the menu is now displayed and that there was a choice of main meal and dessert at lunchtime. The statement of purpose and the service user guide record details about service user’s maintaining contact with family and friends. There is an informative visitors policy in place. There is evidence that visits by relatives and friends are encouraged and are recorded in a service user’s care plan. The minutes of staff meetings indicate that discussions take place about service users exercising choice and control over their lives, and recording in care plans supports this. Information about advocacy services is now available in the home, both in service user’s bedrooms and in the entrance hall. St Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 13 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, 17 and 18 There is a procedure in place that is readily available to service users and visitors to enable them to complain. Staff are aware of and follow policies and procedures that are in place to protect vulnerable service users from abuse. EVIDENCE: There is a satisfactory complaints policy and procedure in place. This is included in the service user guide, which is placed in each service user’s bedroom and in the hallway. There is a complaints log in place and this records that there have been no complaints since the last inspection. Service users and relatives/friends are informed about available advocacy services. Postal votes are arranged for service users but the manager confirmed that service users would be taken to the polling station if they wished to vote in person. Solicitors and other professionals are sought and accessed for service users if professional advice is requested or felt to be needed. There are suitable policies and procedure in place that are designed to protect service users from abuse, such as whistle blowing, management of violence, restraint, gifts and hospitality and the protection of vulnerable adults from abuse. The latter two of these policies have been discussed at a recent staff meeting - this is evidenced in meeting minutes. Staff training on the protection of vulnerable adults from abuse is booked for December 2005 and all staff are expected to attend. St Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24, 25 and 26 The standard of décor at the home is satisfactory and provides service users with a comfortable and homely place to live. A specialist assessment of the premises is needed to confirm that the premises are suitable for the service users accommodated. Service users are not offered the provision of a key to their bedroom door to promote their privacy and independence. Service users are not sufficiently protected from the risk of scalding. Domestic staff are employed in numbers that ensure that the home is clean and hygienic. EVIDENCE: The location and layout of the home is suitable for its stated purpose. One service user continues to be accommodated on the second floor but she has chosen to remain in this room and there is a risk assessment in place. The service user never uses the stairs unaccompanied. There is a maintenance programme in place and the inspector observed that two bedrooms had been redecorated and that new carpets had been fitted. The grounds are kept safe and tidy and are accessible to service users via the provision of a ramp. The fire officer visited the home recently and recommended that seals around fire St Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 15 doors should be replaced. A ‘rolling’ programme to replace these is included on the maintenance programme. There are no CCTV cameras in place. There has been no assessment of the premises by a suitably qualified person but the manager has agreed to arrange this. Moving and handling equipment has been provided, both in communal and private areas of the home. Pressure mats are provided for some service users so that staff can check on them when they get out of bed, so that they can be monitored due to the risk of falls. Mobility hoists are serviced on a regular basis. Service user’s bedrooms are personalised to suit their wishes and are furnished to meet their individual needs. The maintenance programme records that locks will be fitted to bedrooms doors in empty bedrooms, so that any new service users can be offered a key to their room at the time of their admission. Eventually all bedroom doors will be fitted with a lock. Screening is available in double rooms to ensure privacy. There are small safes available for service users should they wish to hold money, valuables or medication is their bedroom. Rooms are centrally heated and heating may be controlled in a service user’s own room. All radiators are covered to prevent the risk of burning. All bedrooms have opening windows and allow access to fresh air and sunlight. A test to detect the presence of Legionella in the water system was carried out in September 2005 and the result was negative. Water temperatures are tested in bathrooms each time someone is assisted with a bath but these tests also need to take place in washbasins in bedrooms to control the risk of scalding. Laundry facilities are satisfactory and the water supply has been checked to ensure that it meets with the Water Supply (Water Fittings) Regulations 1999. The staff rota evidences that domestic staff are employed five days per week. The home was clean and free from offensive odours on the day of the inspection. COSHH data sheets are retained and there is a COSHH policy in place. There is a policy in place for the removal of clinical waste from the premises. There is a satisfactory infection control policy in place and staff are due to attend this training shortly. The laundry room was locked on the day of the inspection to prevent service users entering the room. St Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Staffing levels ensure that service users are safe, and that the premises are clean and hygienic. Recruitment policies and practices at the home do not currently protect service users. Appropriate staff training is taking place to ensure the health, welfare and safety of service users. EVIDENCE: The staff rota evidences that there are two care staff on duty at all times. Volunteers are no longer employed at the home – the manager was informed that there is no problem in employing volunteers, as long as they are appropriately recruited and trained, and that they do not replace staff on the rota. The role of each staff member is also recorded on the staff rota, including ancillary staff. There are eight care staff employed at the home – one member of staff has achieved NVQ Level 2 in Care and is continuing with Level 3 training. Three members of staff are currently undertaking NVQ Level 2 in Care. It is anticipated that 50 of care staff will have achieved this award by mid 2006. New staff at the home are undertaking an Induction training programme that meets Skills for Care specifications. Recruitment and selection at the home falls short of current requirements. Two new members of staff commenced work at the home before a POVA first check had been undertaken, although satisfactory checks have since been St Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 17 received. The registered provider was reminded that two written references and a satisfactory CRB check (or a POVA first check in emergency situations) must be received prior to staff commencing work at the home. This has been a requirement at previous inspections and must be adhered to. The application form in use by the home records a person’s employment history and details of training already undertaken by the applicant are held by the home. There is no evidence that information is obtained by the home and then retained (such as copies of passports and birth certificates) to confirm identification. There is now an effective training and development plan in place. First aid training is booked for the 7th October and six staff will be attending. Vulnerable adults training is booked for the 8th December, when four staff will be attending. Ten staff have been identified as needing medications training and the home is waiting for a date to be confirmed by a training provider. All staff have an individual training record and training certificates are retained by the home. St Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 18 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, 32, 33, 34, 35, 36, 37 and 38 The home is being managed effectively but consideration needs to be given to the requirement for a qualified person to manage the home. The quality assurance system needs to be further developed to enable service users and other stakeholders to affect the way in which the home is operated. The lack of a business and financial plan makes it difficult to confirm financial viability. The financial interests of service users are protected by the systems in place at the home. Written statements designed to protect the health, safety and welfare of service users need to improve. EVIDENCE: The registered provider/manager has many years experience in the caring profession, including management experience. No progress has been made with NVQ Level 4 in Care or Management and the registered provider/manager was reminded that there must be plans in place for there to be a registered St Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 19 manager in post who has achieved these qualifications. The registered provider/manager was advised that she should keep her own practice up to date by attending training sessions arranged for staff and by obtaining up to date information. The new manager is considering undertaking NVQ Level 4 training and it is possible that she will be considered as a suitable candidate to apply for registration with the CSCI. The new manager has taken over some of the duties of the registered provider/manager such as staff training, staff supervision and staff meetings. Morale has improved at the home since these formal structures have been introduced and there are now clear lines of accountability in place. Staff have been issued with the Code of Practice set by the General Social Care Council. There are strategies in place to enable staff to affect the way in which the service is provided – regular staff meetings are now held and a staff questionnaire has been devised as part of the quality assurance system – this has yet to be put into use. There is a quality assurance policy in place and staff meetings are held monthly. Minutes of these meetings evidence that staff are able to offer suggestions and are consulted about the service provided to service users. Quality audits and questionnaires to distribute to service users and visitors have been developed. These systems have now to be put into place to enable the quality of the service provided by the home to be measured internally. There should also be an annual development plan in place. Some new policies and procedures have been developed but there should be evidence that existing policies and procedures are reviewed regularly to ensure that they remain relevant. There is no business and financial plan in place and concerns have been expressed about financial viability – there have been occasions when staffs pay cheques have not been cleared by the bank and the fees paid to the Commission for Social Care Inspection are overdue. Despite the inspector being told that these fees would be paid immediately, they had not been paid on the date that this inspection report was written. There is appropriate insurance cover in place. Records are now kept of all transactions entered into by the registered person. The manager has recently developed a database to record all financial transactions made on behalf of service users – until recently, no records were held of these transactions. There is now an effective system in place, and this includes individual receipts being obtained for all items purchased for service users. Goods are purchased for service users and relatives or representatives are sent an account for these items when account fees are requested. There are plans in place for a ‘cash float’ to be held for each service user so that monies can be accessed quickly. St Judes DS0000019726.V253676.R01.S.doc Version 5.0 Page 20 There is now a satisfactory staff supervision system in place – this has only recently been developed so it is not yet possible to determine if staff will have formal supervision six times per year, as planned. The home’s programme for staff supervision includes ancillary staff as well as care staff. Record keeping at the home has improved. Care plans are held securely and service users are aware that they have access to information held about them. Weekly in house tests of the fire alarm system take place but the monthly fire drill ceased in June 2005 and must be reinstated. The fire alarm system, emergency lighting and fire extinguishers were tested in September 2005 by a qualified contractor. There is a fire risk assessment in place. The passenger lift and hoists were serviced in September 2005. There is a gas safety record in place and the minor electrical works installation was checked in March 2004. A portable appliance test was carried out in March 2005. Accidents are recorded appropriately. Work has commenced on preparing a written statement of the policy, organisation and arrangements for safe working practices, including risk assessments. There is a written document in place for the use of the second floor bedrooms and for the administration of medication. This work needs to continue to include all safe working practice topics. There is a policy in place about routine safety checks. A test to detect the presence of Legionella in the water system was carried out and the results were negative. The water temperature in bathrooms is tested every time a service user is assisted with a bath. There is evidence that staff are undertaking initial training or refresher training on health and safety topics such as food hygiene, infection control, moving and handling and health and safety. Induction training meets Skills for Care specifications on health and safety topics. St Judes DS0000019726.V253676.R01.S.doc Version 5.0 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 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X 2 X 2 2 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 1 3 2 3 2 St Judes DS0000019726.V253676.R01.S.doc Version 5.0 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 OP9 Regulation 13 & 18 Requirement Staff that administer medication must undertake accredited training. The medication policy must include information about controlled drugs. Two written references and a satisfactory CRB check (or POVA first check) must be obtained prior to staff commencing work at the home. There must be a business and financial plan in place at the home that is open to inspection and reviewed annually. Timescale for action 31/12/05 2 OP29 18 & 19 29/09/05 3 OP34 25 31/12/05 St Judes DS0000019726.V253676.R01.S.doc Version 5.0 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 Refer to Standard OP3 Good Practice Recommendations There must be evidence that prospective service users are assessed prior to their admission to the home - this assessment should be based on information gained from care management and/or the homes own assessment. There should be evidence that all specialised services offered are based on current good practice guidance. The home should confirm that a service user’s current assessed needs can be met. Formal reviews of care plans must take place for service users who are self-funding. All documentation included in the care plan should be filled in. There should be more evidence that service users are involved in the care planning process. More care must be taken with the dating of records. The registered person should demonstrate that an assessment of the premises has been carried out by a suitably qualified person. Bedroom doors must be lockable and service users must be offered a key to their bedroom door. There must be evidence that water temperatures are tested in washbasins on a regular basis to control the risk of scalding. NVQ training should continue to ensure that 50 of care staff achieve NVQ Level 2 in Care. There must be plans in place for a registered manager to be in post who has achieved NVQ 4 Care & Management. The quality monitoring systems that have been developed must now be actioned to evidence that the quality of the service offered is measured by the home. There should be an annual development plan in place and evidence that policies and procedures are regularly reviewed. The staff supervison system that has been developed must become fully operational to ensure that staff receive adequate one to one supervison. The work undertaken to provide written statements about the organisation of safe working practices should continue until all safe working practice topics are included. DS0000019726.V253676.R01.S.doc Version 5.0 Page 24 2 OP4 3 OP7 4 5 6 7 8 9 OP22 OP24 OP25 OP28 OP31 OP33 10 11 OP36 OP38 St Judes Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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