Inspection on 04/09/07 for St Margarets

This inspection was carried out on 4th September 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Margarets 30/10/08

St Margarets 18/10/06

St Margarets 29/06/06

St Margarets 26/09/05

St Margarets 26/05/05

St Margarets 10/08/04

St Margarets 04/05/04

Similar services:

Claremont House

Oak Ridge

Coopers Mill Ltd

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Paradise Lodge

Bilney Hall

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

CARE HOMES FOR OLDER PEOPLE St Margarets St Margarets 10 Rothsay Road Bedford Bedfordshire MK40 3PW Lead Inspector Ansuya Chudasama Unannounced Inspection 4th September 2007 10:30 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 Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Margarets Address St Margarets 10 Rothsay Road Bedford Bedfordshire MK40 3PW 01234 345964 01234 345964 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) Calsan Limited Mary Theresa Cook Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Learning registration, with number disability over 65 years of age (21), Old age, not of places falling within any other category (21), Physical disability over 65 years of age (21) St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2006 Brief Description of the Service: St Margaret’s is a privately owned care home and is able to accommodate 21 elderly people. The home is an attractive detached Victorian building situated in a quiet residential area of Bedford just a few minutes walk from the banks of the River Ouse. Bedford town centre is also within walking distance, and the home is well served by public transport. The home has 17 single rooms and two doubles; two of the rooms have ensuite facilities. The home has a lift, and an extension has been added to the kitchen area. The extension also provides a staff room and two additional toilets. There are public parking bays to the front of the home, (pay and display) and a parking bay for the disabled is provided. The following information about fees was obtained from the home on 18th October 2006: Fees are £425.86 weekly, not inclusive of hairdressing (from £5), or chiropody (£10). Information about the home is given out on request by phone or when visiting. Inspection reports by the CSCI are displayed on the notice board of the home. St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key inspection, took place at 10.30am on the 4th of September 2007. The inspector was assisted by the deputy manager and by one of the directors of the home. During the inspection, the inspector spoke to the people living in the home, and the staff on duty. She also looked at some of the records kept about the home and the people living in the home. A tour of the premises was undertaken. Some of the people living in the home could not communicate verbally, so the inspector spent time observing the support the people received from the staff. The information from the ‘service users’ and ‘staff questionnaire’s and the completed Annual Quality Assurance Assessment (AQAA) form sent to the CSCI by the home have been used in this report. A visitor visiting a family member living in the home gave positive feedback about the home. The inspector would like to thank the deputy manager, staff and the people living in the home for the support and time they gave to this inspection. This inspection report should be read alongside the National Minimum Standards for Older People What the service does well: The home has a happy atmosphere and families say the staff have good relationship with the people living in the home. The staff were also said to be ‘friendly and approachable and ready to listen to any concerns’ Comments such as ‘mother eats well’ and ‘never complaints about the food’ and the people living in the home tell the inspector that the ‘food is good here’. This shows the people living in the home enjoy the food at the home. One person using the service stated that the ‘staff make me feel better’ and they ‘look after us well’. One of the people living in the home had returned from hospital and stated that it was ‘good to be back at home’ St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 6 The staff spoken to say that they enjoy working at the home. They attend training to help them meet the needs of the people they look after. They have meetings with their manager to discuss how they are getting on at work. They like working with each other and with the people living in the home. Visitors spoken to state that the staff were very nice and they keep them informed of any thing that happens to their family member. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 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 Margarets DS0000014960.V350311.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5,6 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Prospective service users have the information needed to make an informed choice about living at the home, but not all the people living in the home have a contract to inform them of their conditions of stay at the home. EVIDENCE: The home had a document called the ‘Service Users Guide’ information for residents and their families. This guide also contained some of the information about the Statement of Purpose. The home did not have a separate document called the statement of purpose. If the service user guide document is also to St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 9 be used as the statement of purpose. The home needs to ensure that all the information stated in schedule I of the National Minimum Standards for older people is also included in this document. Since September 2006, it has been a requirement that the service users guide includes the fees charged for living in the home. The guide contained useful contact telephone numbers and details of the CSCI. It would also be good to have the details of Bedford and Luton social services numbers for people living in the home. The records of three people living in the home were inspected. Two of the people using the service had an assessment undertaken prior to admission details completed by the home. However a new person who was admitted to the home did not have an assessment undertaken by the home. A basic assessment, which was completed by the funding authority, was seen. One of the visitors spoken to stated that they had visited the home and were given information about the home. This was also confirmed by most of the ‘service users’ questionnaires completed and sent to the CSCI. The records for three people living in the home were case tracked. These people did not have the terms and conditions of their admission in their files. The deputy manager on duty was not able to find these documents. The home does not provide intermediate care. St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Not all the people living in the home had care planning documents but they have access to health care services that meet their assessed needs within the home. EVIDENCE: The care files of three people living in the home were inspected. Two out of three people had care plans. The new person who had been admitted to the home recently did not have a care plan or risk assessment undertaken. The staff on duty stated that these were going to be done this week, as they got to know the person better. One of the care plans inspected showed that some of the areas for example personal care needed expanding. Also information read in the file showed that St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 11 the person had two carers but this was not stated in the plan. Information recorded in the pressure sores area talked about the person ‘eating a high protein diet’. But this was not mentioned in diet section of the plan. The information read in the files showed that the district nurse visited one of the people that were being case tracked. But this information was not discussed in the care plan. The plan also did not state how staff was managing the person’s continence needs. The medication records showed that staff used anti septic cream for this person. But this was not recorded in the care plan. Information about visits by the GP and other professionals were being recorded. Information discussed in the risk assessments was not always recorded in the care plan. For example one risk assessment talked about using a hoist but the care plan did not mention that this equipment was being used, but it did say a sliding sheet was being used The nutrition list risk assessment stated that there was minimal risk. However the information read for September 07 showed that the person’s needs had changed. But the nutrition list risk assessment had not been reviewed since March 2007. The inspector was informed that the organisation had reviewed their care plans and a new format had been introduced. This format covered a lot of information in detail. A copy of this was seen at the inspection. The medication cupboard and controlled drugs and the medication records inspected seen were satisfactorily maintained. Only staff that are trained in the medication procedures gave out medication. The staff were observed giving out medication to the people living in the home. This was done satisfactorily. One of the people living in the home was observed desperately wanting to go to the toilet. However by the time the staff assisted, the person had an accident. The staff dealt with the situation with sensitivity and well. There was a buzzer in the room near the door entrance and this was tied up and not within the reach of the people living in the home. The staff need to ask the people living in the home who need the assistance of staff to go to the toilet more regularly. St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Menus are not displayed and the people living in the home are not aware of what is for dinner but the food in the home is of good quality EVIDENCE: The inspector sat mostly in the main lounge with the people using the service. She was asked by one of the people living in the home what was for lunch as she was not aware of this. The staff in the room were also not aware of this information. This information was not displayed in the communal areas. The inspector was informed that this information was kept in the kitchen. This information needs to be displayed where the people who use the service can view it. The home had the date displayed on the wall but this was observed to be too low for the people living in the home to see. The staff were observed serving tea and biscuits at 10.30am. They were observed being kind and helpful to the St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 13 people that they served. One staff gave out a cup of tea to one of the people sitting in the lounge. However the person was unsteady and unable to hold on to the cup, and there fore spilled some of the tea from the cup. The staff helped by moving a small table from another person sitting next to this person. This was so they could rest the cup on the table. However the tea that was already on the table was not within easy reach of the other person. An assessment needs to be carried out for all the people living in the home to find out who requires a small table to put their drinks on. At 11am the staff brought in jugs of cold drinks. All the people in the lounge were asked what they wanted to drink. The other lounge with dinning area did not have these drinks in the room. At lunch time the inspector observed that not all the people were offered a drink. The staff were observed serving and assisting the people living in the home in a kind manner. The people that were being feed by staff did this in a sensitive and caring manner. The staff were also observed talking and encouraging the people to eat. One of the people using the service asked the inspector to put the music on when having lunch. The expressions on the people’s faces showed that they enjoyed this. The staff should ask the people in the home if they would like soft music playing in the background when having their meal. The inspector observed the people living in the home have lunch. The main dinning room was not big enough to accommodate all the people living in the home. Some of the people had their lunch in the lounge with the dining table. And one person had their lunch sitting in their chair in this room, as it was their choice. Two people had their meals in the lounge. It was stated that this was their choice. However one of the people had only been admitted to the home yesterday and there was nothing recorded in their files to say that this person wanted to eat in the lounge. Observation showed that there was not enough room for a member of staff to sit in the dinning room to feed this person. The home needs to record in the care plan of the people living in the home that have agreed to have their meal in the lounge or sitting in their chair. And their family needs to be informed of this. Some of the people using the service stated that the ‘meal is tasty’ and it’s a happy home and ‘staff make me feel better’ and they are nice. The communication records showed that families or friends of the people living in the home visited them regularly. It was also stated that they visited the home when they had special events. One of the people living in the home was discharged from hospital on the day of the inspection. This person told the inspector that they were glad to be back home. St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 14 On the day of the inspection the staff took some of the people out in the garden for a little while. The home also had an activities person who did a music quiz for an hour. This was held in the main lounge. Some of the people participated with this and enjoyed this. A risk assessment needs to be undertaken because the inspector observed that the room became crowed and some people living in the home were observed struggling to get out of the door. Some of the people living in the home were observed looking bored. The inspector spoke to some of the people and it was stated that they were bored. This was also noted in the questionnaires received by the CSCI. The home had an activities list but this did not state when the activity was to start and how long this was going to last for. The activities were not suitable to meet the needs of all the people living in the home. For example hairdressing, manicure, videos, and newspaper discussion was recorded as an activity. The home needs to undertake a needs assessment on all the people living at the home to find out what kind of activities they would like to undertake. These need to be recorded in their care plan. The staff were observed trying hard to do activities with the people living in the home. However this was being done in an ad hoc manner. For example a member of staff would start an activity. But they would have to leave in the middle of the game, as they were needed to help out with personal care. The option of having an activities coordinator was welcomed by staff spoken to. St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure and the representatives of the people living in the home have a good understanding of how to make a complaint to ensure that the needs of the people living in the home are met. EVIDENCE: The home has a complaints policy and this was displayed on the notice board. There was also information about how to complain in the service user guide. However the information about the time scale in which the complainant can expect a response needs to be stated in the guide. The inspector was informed that the home had not received any complaints. The questionnaires received from families showed that they knew who to talk to if they were not happy about any thing in the home. The inspector was informed that the home held ‘service users’ meetings every three to six months. This was to get the views of the people and discuss any concerns any one had. The inspector had a discussion with one of the directors regarding involving families at the meeting to get the views of the St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 16 people living in the home that are unable to this. It was stated that this was going to be looked at. The staff records inspected showed that the staff had completed the training on protecting vulnerable adults. The staff files inspected showed that protection of vulnerable adults procedures were being followed. St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service The people in the home live in a homely environment that is clean and tidy. EVIDENCE: The home was clean and tidy. Families also stated this in the questionnaires. The information in the AQAA stated that the home was waiting for ‘council grant as proposed to renew carpets, curtains, and TV’ in the lounge. On the day of the inspection, the inspector was informed that the lounge was being redecorated. The inspector had spent most of the time in this lounge, observation and discussion with staff showed that the room had too many St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 18 things. The staff and the director of the home stated that when the lounge was being redecorated, this was going to be looked at. The bushes in the front of the garden had over grown. This was discussed with the staff. The bushes were cut back by the handyperson straight away. The inspector also observed that the carpet between the room of the corridor and the lounge was not safe as it moved. Also the door of the corridor leading into the garden was not safe. The drain also wobbled when walking on it. There were also two chairs near the door and it was observed that these were seen as a health hazard. A tour of the home showed that the staff had removed the chairs, and the carpet pieces near the doors. The drain was also made more secure. St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home ensures that all staff within its organisation receives relevant training that is focused on improving outcomes for people using the service. EVIDENCE: The staff spoken to enjoyed working at the home. It was stated that this was a happy home and clean. The staff were observed working and communicating well with the people living in the home. Most of the staff had worked at the home for a number of years. The information from the AQAA also stated that one full time and one part time staff had left employment in the last 12 months. This meant that the people living in the home have continuity of staff working with them. Records showed that the new staff completed the home’s induction training but this needs to be recorded. It was stated by some that they had completed NVQ level 2 and some were doing NVQ level 3. Information from the AQAA stated that the home had 15 care staff and 8 staff had NVQ Level 2 or above training. And 5 staff were St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 20 working towards NVQ Level 2 or above. The information in the AQAA also stated that all staff who administered medication had received this training. All staff had received training on moving and handling and safe food handling. most of the staff had undertaken training on dementia care and aggression. One staff spoken to stated that they had supervision on a monthly basis. The staff records inspected showed that supervision was being carried out on a two monthly basis. Three staff recruitment records were inspected. Records showed that the recruitment procedures were being carried out satisfactorily. However one staff did not have a proof of identity photograph. St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although procedures are in place, inadequate care planning and risk assessments place users at risk. EVIDENCE: The staff spoken to stated that they received support from management. This was also confirmed from the questionnaires received by the staff. St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 22 Health and safety issues must be addressed; in particular with new people being admitted to the home with out the homes assessment being undertaken. And also no care planning or risk assessments being carried out by the home. It was also stated that staff were sometimes not given up to date information about the people they support with regard to their care plans. The fire alarm system and emergency testing was being carried out regularly. The Fire drill was completed on the 20/10/06 and another one had been completed on the 26th of March 07. The fire officer had visited on the 23rd of April 2007. Several areas of deficiency were recorded. One of the deficiency was that the fire safety risk assessment was not suitable and sufficient. The home had submitted a plan on the 3rd of August 07 to the fire officer. However this was still not met. The inspector was told by one of the proprietor that they were still working on this and a folder had been created for other deficiency areas identified in the report and they were working on this. The inspector was informed that the home sends out questionnaires to families, staff and the professionals randomly. The inspector asked to see the analysis of these surveys. It was stated that this information was discussed with staff and the outcome was put in practice. The home needs to undertake an analysis from the questionnaires. This information needs to be displayed as stated in the service user guide. The home did not have an annual development plan that met the standard. The inspector was informed that the organisation was working on undertaking an annual audit of the service. The inspector was informed that the home did not hold any money for the people living in the home. It was stated that the home paid for the services the people in the home purchased. The home then send the family’s the invoices to pay for the services used. This information needs to be stated in the care plan of the people using the service. St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP3 Regulation 4, 14 Requirement The manager must ensure that all new people being admitted to the home have a needs led assessment carried out to meet the needs of the people living in the home. The manager must ensure that all the people living in the home have care plans to meet the needs of the people using the service. The manager must ensure that all the people living in the home have risk assessments carried out as stated in the regulation to keep them safe Timescale for action 30/10/07 2 OP7 14, 15 30/10/07 3 OP8 13 30/10/07 4 OP38 13 Review the risk assessments of the people living in the home to ensure the information is updated with changing needs Undertake a risk assessment for 30/11/07 some of the activities undertaken in the main lounge. St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 25 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 OP8 Good Practice Recommendations The documentation of skin and sore assessments should be improved. This recommendation was not inspected on this inspection but it will be looked at the next inspection. A response from the provider stated that this was better managed. CSCI Bedford office should be notified in writing once the pre-set mixer valve has been fitted. This recommendation was not inspected on this inspection but it will be looked at the next inspection. A response from the provider stated that this was replaced immediately. The procedure for advertising jobs should be clear so that this can be followed consistently. This recommendation was not inspected on this inspection but it will be looked at the next inspection. A response from the provider stated that this was advertised through the job centre. 2. OP38 3. OP29 St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Boddingtons Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Margarets DS0000014960.V350311.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!