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Inspection on 19/06/06 for St Margaret`s Ltd

Also see our care home review for St Margaret`s Ltd for more information

This inspection was carried out on 19th June 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Management had worked with the Commission to meet and improve standards. Practice in the home did not generate many complaints. Management and staff worked to provide a homely atmosphere for residents. The home benefited from having a stable staff team.

What has improved since the last inspection?

Improvements continued to be made to medicine management and a new medicine fridge had been provided. Care plans continue to improve with staff being receptive to advice on developing these. The manager was making progress with updating policies and procedures. Decisions had been made by the registered person with the manager to start work on improving the environment.

What the care home could do better:

Amendments must be made to the Statement of Purpose and a Service Use Guide must be provided. Residents must only be admitted who are in the home`s category of registration, have a pre-admission assessment of need completed by arelevant person and receive written confirmation that the home can meet their assessed needs. More efforts must be made to involve residents or their representatives in preparing care plans and social care plans. Further improvements were needed to medicine management. Staff must have access to clear adult protection procedures. Staff must be recruited in line with regulation and must have access to regular supervision and relevant training. The registered Person must ensure visits are made to the home as required by regulation 26. A quality assurance system must be introduced and efforts made to obtain the views of residents and relatives about the quality of the service. A fire risk assessment must be completed on the premises. A system should be implemented to ensure maintenance and safety systems are completed routinely.

CARE HOMES FOR OLDER PEOPLE St Margaret`s Ltd 3 - 5 Priestland`s Park Road Sidcup Kent DA15 7HR Lead Inspector Ms Pauline Lambe Unannounced Inspection 19th June 2006 09:40 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 Margaret`s Ltd DS0000006785.V290691.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 Margaret`s Ltd DS0000006785.V290691.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Margaret`s Ltd Address 3 - 5 Priestland`s Park Road Sidcup Kent DA15 7HR 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) 020 8300 2745 Mr Al-Naseer Hudda Mrs Linda Masher Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places St Margaret`s Ltd DS0000006785.V290691.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 22 Male or Female - OP (Old age) Date of last inspection 26th January 2006 Brief Description of the Service: St. Margarets is privately owned by Mr and Mrs Hudda and has been registered since 1971. The home is registered to provide care and accommodation for 22 older people. The Home is a large detached two-storey property, which includes a purpose built extension. A lift is available for the residents. St Margarets is located in a residential area close to transport and shops. There are three double and sixteen single bedrooms, fourteen of which have en suite facilities. There are two bathrooms with WCs and three further WCs. A small lounge is situated at the front of the building. In addition there is a large lounge/dining room, which looks onto the attractive garden at the rear of the property. Residents have access to health care services via the local GP practice. The fees in the home at the time of inspection ranged between £435.00 and £565. Residents paid privately for personal items, hairdressing and newspapers. St Margaret`s Ltd DS0000006785.V290691.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this unannounced inspection was completed on 19th June 2006 over 7 hours. The manager and staff assisted with the inspection. Twenty-two residents were in home. One of the registered providers was in the home for a short period and spent time talking to the inspector. The service was last inspected on the 26th January 2006. The inspection included a review of information held on the service file, a tour of the premises, inspection of records, talking to residents, relatives, staff and the manager and reviewing compliance with previous requirements. Contact was made with relatives and other interested parties to get their views of the service. Although efforts had been made to meet requirements made at the last inspection a number of these have been restated in this report. The registered provider must work with the manager to ensure requirements are met and the home complies with regulation and the Commission will monitor progress made. What the service does well: What has improved since the last inspection? What they could do better: Amendments must be made to the Statement of Purpose and a Service Use Guide must be provided. Residents must only be admitted who are in the home’s category of registration, have a pre-admission assessment of need completed by a St Margaret`s Ltd DS0000006785.V290691.R01.S.doc Version 5.1 Page 6 relevant person and receive written confirmation that the home can meet their assessed needs. More efforts must be made to involve residents or their representatives in preparing care plans and social care plans. Further improvements were needed to medicine management. Staff must have access to clear adult protection procedures. Staff must be recruited in line with regulation and must have access to regular supervision and relevant training. The registered Person must ensure visits are made to the home as required by regulation 26. A quality assurance system must be introduced and efforts made to obtain the views of residents and relatives about the quality of the service. A fire risk assessment must be completed on the premises. A system should be implemented to ensure maintenance and safety systems are completed routinely. 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 Margaret`s Ltd DS0000006785.V290691.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 Margaret`s Ltd DS0000006785.V290691.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): 1, 2, 3 and 4. Standard 6 did not apply to the service. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. The admission procedures and information about the service needed improvements. EVIDENCE: A statement of purpose was provided but needed some amendments to ensure it complied with regulation. A service user guide was not provided and must be prepared and made available to residents and others. Copies of the inspection reports were seen in the front hall. Contracts were seen for residents but these did not reflect the fees or show who was responsible for paying these. Care records for three residents were viewed. Pre-admission assessments had not been completed for all these residents. When a resident visited prior to admission the manager completed an assessment during the visit but not all residents were able to visit prior to admission. Some care manager assessments were seen for residents though it was difficult to assess whether these were received prior to admission. Since the last inspection one resident St Margaret`s Ltd DS0000006785.V290691.R01.S.doc Version 5.1 Page 9 had been admitted who was outside the home’s category of registration. The manager was advised of the need to apply to the Commission for a variation to registration prior to the admission of a resident outside the home’s category of registration. Of the three resident files viewed only one contained written confirmation that the home could meet the residents assessed needs. Requirements 1 and 2 and recommendation 1. St Margaret`s Ltd DS0000006785.V290691.R01.S.doc Version 5.1 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 and 10. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. Care plans were satisfactory and residents had access to health care services. Although medicine management continues to improve some concerns were noted particularly in relation completing an audit trail. Residents were satisfied with they way they were treated by the staff. EVIDENCE: Three resident’s care plans were viewed. These were satisfactory but did not show how all care needs and risks to residents were to be managed. For example one resident did not have a risk assessment or care plan in place in relation to smoking. One resident had been admitted with a diagnosis of dementia but no care plan was prepared to show how this need was to be met. Care plans were reviewed and there was some evidence of relative involvement. Residents were registered with a G.P and staff made arrangements for residents to access dental and optical services. The manager had completed a course on ‘foot care’ and provided this to all residents except those suffering with diabetes. Residents with diabetes received chiropody services from the St Margaret`s Ltd DS0000006785.V290691.R01.S.doc Version 5.1 Page 11 NHS. Records were kept for all accidents to residents and those seem were well completed. Regulation 37 notices were sent to the Commission as required by regulation. Medicine policies and procedures were provided but the manager had yet to prepare a policy regarding residents who choose to self medicate. At the time of this inspection none of the residents managed their own medicines. Medicines were safely stored and a medicine fridge had been provided since the last inspection. Administration charts were quite well maintained but care must be taken when punching holes in these for filing that information about the medicine is not obscured or removed. Most of the requirements made at the last inspection in relation to medicines had been met. Medicine management training fro staff was planned to take place on 13/07/06. The supplying pharmacist was in the home and spent time talking to the inspector about the regulations and standards in relation to medicine management. The manager said that all residents had an annul medicine review completed by a pharmacist attached to the GP practice. Medicines for three residents were checked and a number of inaccuracies were found. For example when doing an audit trail three medicines had too many in stock and one was short based on the amount supplied and administered. One strip of Paracetamol tablets for a resident had been removed from its original container so could not be counted. Hand written entries on administration charts did not include the information as printed on the pharmacist’s label and had not been signed by two members of staff. Residents who spoke to the inspector said staff treated them with respect. Staff were observed interacting appropriately with residents, answering call bells and responding to resident requests for assistance. Requirements 3, 4 and 5. St Margaret`s Ltd DS0000006785.V290691.R01.S.doc Version 5.1 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): 12 – 15. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Residents were generally satisfied with the activities and meals provided. Residents and relatives seen said visitors were made feel welcome and residents indicated they could make choices about their lives. EVIDENCE: The majority of residents were seen sitting in the lounge watching T.V. Activity records showed residents participated in a variety of activities. Staff said activities were provided in the afternoons. A number of residents went out with relatives and an outing to Hastings was planned for August this year. A number of residents said they got bored, found the days long and watched too much T.V. They said they did enjoy some activities especially the music sessions but felt more could be provided. When asked what they would like to do a number of them said they did not know or that they ‘were happy to sit and watch the world go by’. It was suggested at the last inspection that the manager had a meeting with the residents to discuss this issue and this advice was repeated on this occasion. St Margaret`s Ltd DS0000006785.V290691.R01.S.doc Version 5.1 Page 13 The home had an open visiting policy and residents said they enjoyed visits and outings with family and friends. Visitors seen said they were made feel welcome by staff when visiting the home. Residents said they made decisions as to how they spent their day and how they liked to dress and present. By involving residents more with care planning the home could evidence the level of personal choice residents made. Residents were generally satisfied with the meals provided. A number of residents said the food was ‘very good’. Recently staff held a meeting with residents to discuss their views on having a full cooked breakfast on Sunday and a light lunch and having a roast dinner on Mondays. The residents decided this suited them. A few residents said that some meals provided were not to their liking particularly the current evening meal, which consisted mainly of sandwiches. This was brought to the attention of the manager for her to address with the staff and residents as the menus seen indicated a choice of meal was provided in the evening. During lunch it was evident residents enjoyed their meal, had a choice of meal provided and staff offered assistance where needed. Senior care staff prepared and cooked meals a cook was not employed. All care staff had done food hygiene training. Recommendations 2 and 3. St Margaret`s Ltd DS0000006785.V290691.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. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. A satisfactory complaints policy was provided but eh one on adult protection required some amendments. Staff displayed an awareness of adult protection but no training had been provided on this topic for some time. EVIDENCE: The home had an adequate complaint policy in place and a system to record complaints made about the service. Since the last inspection no complaints had been made about the service to the home or the Commission. Residents who spoke to the inspector said if they had concern they would discuss this with the manager, a member of staff or their family. Feedback received from relatives indicated they were aware of the home’s complaints policy. One relative indicated they made a complaint one occasion and this was resolved to their satisfaction. The adult policy and procedure had not been reviewed as advised at the last inspection. The manager said she had contacted Bexley Social Services to get a copy of their adult protection procedures but had not yet received this. In discussion with staff it was evident they had a working understanding of adult protection and what to do if this was suspected. No training had been provided for staff on this topic for some time. The inspector advised the manager to contact Bexley Social Services about this as they provided basic awareness training and update training for staff. Requirement 6. St Margaret`s Ltd DS0000006785.V290691.R01.S.doc Version 5.1 Page 15 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, 24 and 26. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. The reason this section was assessed as good was based on the information provided about the planned upgrading of the environment. The home was safely maintained and residents were satisfied with the personal and communal space provided. EVIDENCE: The home was adequately maintained but as mentioned at the last inspection the environment was looking tired and dated. Since then plans have been put in place to start a redecoration and refurbishment programme. The first areas to be addressed will be the corridors and communal areas. The registered person and manager agreed to send a programme for this work to the Commission indicating the planned start and finish dates. Staff recorded repairs and maintenance issues and when the maintenance technician visited and completed the work he indicated this had been done on in the book. Bedrooms seen were clan, tidy and free of offensive odours. Residents seen said they were satisfied with their bedrooms and were able to bring in small St Margaret`s Ltd DS0000006785.V290691.R01.S.doc Version 5.1 Page 16 personal items such as photographs, ornaments, pictures and small furniture items. Requirement 7. St Margaret`s Ltd DS0000006785.V290691.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 – 30. Quality in this outcome area was poor. This judgement has been made using available evidence including a visit to the service. Adequate staffing levels were maintained. Recruitment procedures were poor and posed a risk to residents. There was no evidence that any staff training had been provided since the last inspection and efforts must be made to increase the percentage of care staff achieving NVQ 2 qualification. EVIDENCE: The staff team comprised of a manager, senior carers, care assistants and domestic staff. A maintenance technician visited the home on request to undertake repairs and health and safety work. Staff rotas seen showed that adequate staffing levels were maintained. Staff rotas must include the full name and designation of the employee. Staff displayed an understanding of the residents and their care needs and were observed interacting with them appropriately. Comments made by residents included ‘staff are wonderful’ and ‘staff are very good and know their job’. Senior staff in the home said they planned to retire in 2008 and therefore do not plan to complete NVQ training. Five of the remaining twelve carers employed had achieved NVQ 2 or above. Efforts must be made to increase this to ensure 50 of care staff have this qualification. Recruitment practices were poor and an immediate requirement was left for the manager to address this issue urgently. None of the employee files viewed St Margaret`s Ltd DS0000006785.V290691.R01.S.doc Version 5.1 Page 18 complied with regulation and a requirement made at the last inspection was not met. There was no evidence to show that staff had received training relevant to their role since the last inspection. The manager said that she had attended training on food safety in May 2006 but had not received a certificate of attendance. Requirements 8 and 9 recommendation 4. St Margaret`s Ltd DS0000006785.V290691.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, 35, 36, 37 and 38. Quality in this outcome area was poor. This judgement has been made using available evidence including a visit to the service. Safety records seen were up to date and showed attention was given to providing a safe environment. The registered person did not provide any reports on regulation 26 visits nor was there a quality assurance system in place. Staff did not receive supervision fire drills were not held at times to include night staff. EVIDENCE: The registered manager has been in post for a number of years and has the experience needed to manage the service. The manager said that as she plans to retire in 2008 she did not intend to undertake any NVQ training. The manager presents as being willing to work with the Commission to meet and meet and raise standards in the home. The Commission had not received any reports in relation to regulation 26 visits by the registered person. There was no evidence to show that a quality St Margaret`s Ltd DS0000006785.V290691.R01.S.doc Version 5.1 Page 20 assurance system had been implemented or that meetings had been held with residents or relatives. These issues were discussed with the manager at the last inspection and again with both the manager and registered person at this inspection. No staff supervision was being provided at this time. The manager and senior staff worked with carers and took the opportunity to supervise their practice but this supervision was not recorded. The manager had worked hard to ensure staff had access to policies and procedures relevant to running a care home. Work was still in progress to ensure all of these were up to date. A selection of safety records were inspected, these included gas safety, electricity, fire safety, hoist service, lifts service and water chlorination. All records seen were up to date. The home did not have a fire risk assessment for the building and a requirement in relation to this made from the last inspection had not been met. The manager had provided fire safety training for staff in June 2006. The manager must check with the fire service that she is a ‘competent person’ to undertake this training. Fire drills had been held but none at times to include night staff. The home did not have a health and safety policy signed by the registered person and this issue was raised at the last inspection. The manager said that the maintenance person checked hot water temperatures but there was no records kept to show that this was done. Hot water temperatures checked during the inspection were at a safe level. Requirements 10 to 15. St Margaret`s Ltd DS0000006785.V290691.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 2 3 1 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X X 1 3 2 St Margaret`s Ltd DS0000006785.V290691.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 OP1 Regulation 4 Requirement The registered person must ensure the home provides an up to date statement of purpose and that a service user guide is provided that complies with regulation and schedule 1. A copy of the revised documents must be sent to the Commission. The registered person must ensure: • Residents are admitted to the home based on an assessment of need. • Residents must receive written confirmation that based on assessment the home can meet their needs. • Residents must not be admitted to the home that are not included in the home’s category of registration. • An application to vary registration must be made to the Commission for the resident recently admitted outside the home’s category of registration. DS0000006785.V290691.R01.S.doc Timescale for action 26/08/06 2. OP3 14 27/07/06 3. OP4 14 27/07/06 St Margaret`s Ltd Version 5.1 Page 23 4. OP7 15 5. OP9 13 6. OP9 13 7. OP18 13 8. OP19 23 The registered person must ensure care plans are prepared for each resident to show how all identified care needs and social needs will be met. The registered person must ensure a policy and procedure for self-administration of medicines is developed. (Timescale of 20/04/06 was not met) The registered person must ensure • Hand written entries made on administration charts include the same information as the pharmacist’s label and are signed by two members of staff. • Medicines must not be removed from their original containers. • Medicine records must be kept in such a way as to enable an audit trail to be complete. • In view of the medicine errors noted the manager must complete regular checks of medicine stock to ensure these are being managed safely and administered to residents as prescribed. The registered person must ensure that the policy and procedure in relation to adult protection indicates clearly that all allegations or suspicions of abuse are referred to the local social services department for investigation. The registered person must ensure a copy of the programme for the planned redecoration and refurbishment work sent to the Commission. DS0000006785.V290691.R01.S.doc 27/07/06 27/07/06 27/07/06 27/07/06 27/07/06 St Margaret`s Ltd Version 5.1 Page 24 9. OP29 19 10. OP30 18 11. OP33 26 12. OP33 24 13. OP36 18 The registered person must not employ staff to work in the home unless the person is fit to work in the home and the information required in schedule 2 has been obtained. (Timescale of 13/03/06 was not met.) An immediate requirement was therefore left with the manager to complete an audit of all staff files to ensure these comply with regulation and to send a copy of the audit to the Commission by the date set. The registered person must ensure staff receive training and update training relevant to the work they perform including structured induction training. Records of staff training must be kept and available for inspection. The registered person must ensure visits are made to the home as required by this regulation and a copy of the visit report must be sent to the Commission. (Timescale of 27/03/06 was not met). The registered person must establish a system to review and improve the quality of care provided in the home. The system must include consultation with residents and their relatives and the Commission must receive a report of any review conducted. (Timescale of 27/03/06 was not met). The Registered Person must ensure the home has policies and procedures in place in relation to staff supervision and that staff receive supervision as required by regulation. Evidence of staff supervision must be kept and made available for inspection. (Timescale of DS0000006785.V290691.R01.S.doc 17/07/06 27/07/06 27/07/06 27/07/06 27/07/06 St Margaret`s Ltd Version 5.1 Page 25 14. OP38 23 15. OP38 23 16. OP38 16 27/03/06 was not met). The registered person must ensure a fire risk assessment is completed for the building. A copy of these documents must be available for inspection. (Timescale of 20/03/06 was not met). The registered person must ensure a person competent to do so provides fire safety training for staff. The suitability of the manager to provide this training must be checked with the local fire safety service. Fire drills must be held at times to include all staff including night staff. The registered person must ensure a system is in place to undertake and record routine safety checks such as hot water temperatures on a regular basis and a health & safety policy signed by the registered person must be provided. 27/07/06 27/07/06 27/07/06 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. 3. 4. Refer to Standard OP2 OP12 OP15 OP28 Good Practice Recommendations The registered person should ensure the resident’s contract for service reflects the fees paid and who is responsible for paying them. The registered person should hold a meeting with residents to discuss the provision of activities and ensure they meet their needs and expectations. The registered person should ensure the evening meal suits the residents and includes a choice of meal to cater for the needs of the residents who do not like sandwiches. The registered person should ensure 50 of care staff DS0000006785.V290691.R01.S.doc Version 5.1 Page 26 St Margaret`s Ltd have achieved NVQ2 qualification. St Margaret`s Ltd DS0000006785.V290691.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Margaret`s Ltd DS0000006785.V290691.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!