CARE HOMES FOR OLDER PEOPLE
St Martins Care Home 42 St Martins Road Bilborough Nottingham NG8 3AR Lead Inspector
Susan Lewis Key Unannounced Inspection 6th February 2007 10:00 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 Martins Care Home DS0000002217.V329128.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 Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Martins Care Home Address 42 St Martins Road Bilborough Nottingham NG8 3AR 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) 0115 929 7325 Broadoak Group of Care Homes Mrs Barbara Elsie Nunn Mrs Gail Kirkby Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (21) of places St Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Old age, not falling within any other categort y(OP) (21) Dementia - over 65 years of age (DE(E) (21) Date of last inspection 22nd November 2006 Brief Description of the Service: The fees are social services rates which are for 2006/07 £276-£307. The most recent inspection report is stored in the office. St Martin’s Care Home provides 21 places for older people requiring residential care who also have a diagnosis of dementia. It is situated in a quiet part of Strelley, some three miles north west of the centre of Nottingham. There are bathrooms and toilets to both floors. There is an assisted bath to support residents in bathing. Suitable aids and adaptatations are obtained through the district nursing service. The home has ample communal space and extensive gardens. The home was initially registered in 1995 and subsequently in 2002 with the Commission for Social Care Inspection. The registered company is Broadoak Group of Care Homes. The Registered Provider is Mrs. B. Nunn. St Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation. The inspection was unannounced and took place over 7 hours one Tuesday in February 2007, and was conducted by one inspector as part of the annual inspection process. A partial tour of the building took place and a selection of residents’ bedrooms was inspected. Residents’ and staff records were inspected and five residents and a selection of staff on duty were spoken with. Other information that was used to inform this report was the pre-inspection information provided by the registered manager, accident and incident reports received since the last inspection as well as the previous inspection reports. What the service does well:
The service provides a pleasant environment for residents to live in; they feel safe and well cared for. Activities are provided that meet the needs of the residents ensuring that their cultural needs are met and supported with a staff group that reflects the cultural make up of the home. Meals are provided in a pleasant dining room and residents said that they were good and they had plenty to eat throughout the day. The staff have access to a variety of training and understand the importance of ensuring the safety of the residents by protecting them from abuse. St Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better:
The Registered Person does not always receive the social worker assessment prior to the resident moving to the home. It is essential to minimise risk to residents that assessments are obtained prior to moving to the home or the home carry out their own thorough assessment themselves. Although the manager is currently rewriting all the care plans following Broadoak’s guidelines they lack personal detail about the individual and do not provide clear information on how outcomes are to be met by care staff. This means that residents do not always receive care that is personalised to their needs. There is no evidence that residents or their representatives are involved in creating or reviewing care plans and the Registered Person must ensure that where possible they are involved in this process to show that residents are able to make choices and are in control of their care. It was apparent in discussion with the district nurse that a resident had pressure care needs in reading the residents care plan this was not clear although risk assessments had taken place no care plan was in place to minimise the risk. The Registered Person must ensure that care plans show clearly how residents with pressure care needs are to have those needs met.
St Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 7 Although medication was generally monitored and records were adequate, a number of errors were noted during the inspection and the Registered Person must ensure a more thorough audit process in created to minimise the potential risk. Although activities take place there is no formal system to record what happens throughout the course of the week it is recommended that the Registered Person develop a method of recording this information. The home is registered for people with dementia and it is recommended that the Registered Person make arrangements to support residents to access advocate services to ensure that they rights are fully maintained. It is recommended that the Registered Person create a method of capturing all comments about the service. Staff files although much improved following the last inspection showed that two files checked lacked suitable references. The Registered Person must ensure that the references received are suitable and if they are not make arrangements to obtain a third reference. Specialised training to support staff in working with people with dementia appears to be lacking. The Registered Person must ensure that staff receive training to enable them to do their job. There is no evidence to indicate how the quality monitoring system effects the development of the home as required. There is a need to maintain records of staff supervision to support staff development 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 Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 8 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 Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 9 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): 3 and 6 Quality in this outcome area is poor. Residents occasionally move to the home without an assessment they are not always assured that their needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were viewed as part of this inspection; each plan had an assessment from social services as well as the homes own assessment, which covered all aspects of daily living. The Registered Person must ensure that the assessment informs the care plan in respect of the residents’ health and welfare and that they receive the assessment prior to the resident moving to the home to ensure that all the residents needs are highlighted and that the home are able to meet them.
St Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 10 Intermediate care is not provided in this service. St Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 11 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 and 10 Quality in this outcome area is poor. Care plans do not set out in detail how residents personal and social care needs are to be met and residents health care needs are not always fully met placing residents at potential risk. Poor medication management also potentially places residents at risk. Staff always treat residents with dignity and support their privacy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is currently rewriting the care plans in a standard format that has been created by Broadoak Care. Although the plans are clear and accessible, they did not always provide detail on how and individual needs are to be met. They provided general statements and not how these were to be achieved. St Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 12 The Registered Person must ensure that care plans provide information on how each resident individual needs are to be met. In one case it was noted that the assessment from the social worker contained some important information regarding the residents health this did not appear on the residents care plan. The manager said that this was because the social worker assessment was not received until after the resident came to the home. One resident who had pressure care needs with a district nurse visiting did not have any information regarding what care staff were to provide to minimise the resident’s risk. The manager rewrote this plan during the inspection and as such an immediate requirement was not left. The Registered Person must ensure that all residents who have pressure care needs have care plans that address this issue clearly showing what action staff must take in consultation with the district nurse to minimise risk. Residents spoken with said that they see a GP if they feel unwell and they are able to rest in bed if they want to, this ensures that residents have their health care needs met. Medication is stored in a locked medication trolley in a locked room. Records showed that medication was signed for when it came in and that the medication administration records were signed to show that the medication was given to each resident. During the inspection of one resident’s medication it was evident that the pharmacist was actually sending more medication than was on the prescription. All the documentation from the pharmacist supported that the home was receiving only 28 tablets, but when counting the medication it was clear that 30 tablets were being issued by the pharmacy. Records showed that the home routinely sent 2 tablets back to the pharmacist. This showed that the staff were not thoroughly checking medication received at the home. The Registered Person must improve the method of auditing medication within the home to ensure errors do not occur that may potentially place residents at risk. Due to residents level of dementia they were unable to remember whether they were informed about their care plans, however those spoken with said that they felt staff were very caring and helped them when they needed it and always knocked on the door before entering the bedroom. Staff were observed during the day undertaking a variety of tasks including assisting residents to the toilet, bringing them drinks and each task was undertaken with care and politeness and showed that staff respected the residents’ dignity. St Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 13 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 and 15 Quality in this outcome area is good. Residents are able to take part in a variety of activities that meet residents’ cultural needs and their expectations of living in a care home. Residents are supported to maintain contact with family and friends and maintain control over their lives. Meals are appetising and nutritious. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken with said that they were given choice as to when they got up and went to bed, staff spoken with confirmed that they ensured they asked residents about how they wanted their care and staff were observed asking residents about the support they needed. On the day of the inspection activities were organised both by staff involving residents in a sing a long and quiz as well as a visiting activity person. Who visits the home once a month. The activities arranged were suitable for the
St Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 14 needs of the residents and were varied. Residents could choose to be involved or sit out if they chose to. Records were not very clear as to who took part in activities, although there was some limited information in diary notes. It is recommended that the Registered Person create a record of activities that take place and who takes part to show exactly what is happening for residents. Care plans identified where residents had a religious belief and some identified how this was met with a local minister visiting the home ensuring residents cultural needs are met. Residents confirmed that they were able to see their family and friends when they wanted to and could see them in private if necessary. The staff support residents to maintain contact with family and diary notes showed that relatives visited regularly. There was photographic evidence of activities that resident, staff and families are involved in including Christmas parties and other major events in residents’ lives such as birthdays. This shows that staff at the home recognise the importance of residents celebrating different cultural events. Staff spoken with were able to demonstrate how they supported residents to take control of their lives such as choosing their clothes in the morning to the time they got up and went bed. Residents’ bedrooms are personalised and residents spoken with said that they were able to bring some personal possession to the home. In discussion with the manager it was clear that residents are not routinely advised about contacting advocate support services. It is strongly recommended that residents particularly those with dementia and do not have relatives to support them be enabled to access advocate services. The midday meal was observed and appeared to be appetising and nutritious. Residents spoken with said that ‘The food is very nice and I get plenty, I get my fill’. ‘I like the food and I get plenty’. Staff were observed assisting residents who needed help and staff spoken with were able to identify resident nutritional needs and how they should be met. This ensures residents receive the right food and help to meet their needs. St Martins Care Home DS0000002217.V329128.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 and 18 Quality in this outcome area is good. Residents feel confident that complaints are listened to and that it will be acted upon. Staff are able to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission received one complaint since the last inspection this was treated as an adult protection issue and social services held a strategy meeting. Following an investigation by the Registered Person and social services no evidence was found to substantiate the complaint and the matter was considered closed. No complaints have been received by the home since the last inspection. The home has a detailed complaints procedure, which includes proformas for recording complaints, however the manager has not created a separate file where complaints can be recorded. The manager said this was because she had not received any complaints to date. The inspector pointed out that the manager had indeed received a compliant about a lost ring. All complaints must be recorded.
St Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 16 Staff spoken with knew how to support residents in making a complaint and who to pass the information to. It is strongly recommended that a complaints file be set up and record even small comments for example where something goes missing but is found quickly to show that the staff respond appropriately in these situations. Evidence was seen on staff training records that staff were receiving training on Adult Protection, staff spoken with were able to provide answers on how they would respond if they suspected abuse and understood their responsibility to inform the Registered Person if they suspected abuse. This ensures that residents are protected from abuse. St Martins Care Home DS0000002217.V329128.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 and 26 Quality in this outcome area is good. The home is well maintained and safe for residents and they live in a clean and hygienic setting. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Significant improvements have been made since the last inspection regarding the environment The rubble that had been causing a risk to residents in the garden was being cleared on the day of the inspection and communal areas had been decorated. The home was looking well maintained and clean and hygienic.
St Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 18 Residents spoken with confirmed that their bedrooms were always clean and tidy. Communal toilets and bathrooms provided liquid soap and paper towels to minimise the risk of cross infection. The laundry facilities were appropriate to the size of the home and were clean and well maintained ensuring that infection could be controlled within the home. Staff were observed following good practice and in discussion with staff were aware of the importance of good hygiene to protect residents from infection. St Martins Care Home DS0000002217.V329128.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 and 30 Quality in this outcome area is adequate. Staff are employed in sufficient numbers to meet the needs of residents. The recruitment practices are not robust and do not always ensure residents are protected. Training to ensure staff are competent to do their jobs must be improved to include best practice in working with people with dementia. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff rotas evidenced that sufficient staff were employed each shift. Residents spoken with said that they felt that staff were available to help them when they needed them and through observation it was clear that staff did not have to spend all their time involved in purely care tasks but were able to sit and talk to residents and involve them in different activities. This is good practice. The manager is now employed on a super numery basis and is able to focus her attention on the management of the home. Evidence was provided that by June 2007 100 of all care will have NVQ level 2 or above. This is considered good practice. St Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 20 Three staff records were viewed and evidence was seen, each member of staff had two written references, however two of the files looked at the staff had acted as references for each other. When this is the case the Registered Person must ensure that he is satisfied with the authenticity of references to maintain the safety of residents. Evidence was seen that Criminal Records Bureau checks are made and Protection of Vulnerable Adults (POVA) First checks have been carried out on more recently recruited staff, this ensures that people who are unsuitable to work with vulnerable adults are not recruited. Evidence was seen that staff receive mandatory training and this is renewed at suitable intervals to ensure that practice remains up to date. It was less clear that staff received training on best practice in working with people with dementia. Staff spoken with confirmed that they had received mandatory training but not all staff had received the more specialist training in working with people with dementia. As the home is registered for dementia it is required that the Registered Person ensure that all staff receive training appropriate to the work they perform. St Martins Care Home DS0000002217.V329128.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 and 38 Quality in this outcome area is adequate. The manager is now able to manage the home to ensure she achieves appropriate standards. However it is not always clear that the home is run in the best interests of residents. The health safety and welfare of residents and staff are promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As mentioned previously the manager is now employed on a super numery basis allowing her to manage the home. As this only started two months ago and the manager had a backlog of work to complete the full effects of this
St Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 22 improvement have not yet been realised. In discussion with the manager she is aware of the work that needs to be completed to bring the home up to standard. The Broadoak organisation has a standard Quality review tool, however they was no evidence that this was being used or what happens to the information obtained. The Registered Person must ensure that the system developed for quality monitoring is used to improve and develop the service. The manager does not act as appointee for anyone and residents monies are stored appropriately with records maintained of all transactions this ensures residents are protected from financial abuse. The manager reported having started the process of providing formal supervision for the staff however had not created suitable records for this. It is strongly recommended that the Registered Person ensure that suitable records are created to evidence that regular supervision is being carried out. Evidence was seen that the home improvements have been made in the standard of routine maintenance. The last Environmental Health Inspectors visit was completed 12th December 2006. This made two requirements regarding cleaning contact surfaces to fridge and freezer and removing debris from the dry stores area. This has been completed. It was also recommended that they implement the Safer Food Better Business method of recording information within the home, this also has been complied with. Risk assessments have been completed for safe working practices within the home ensuring both the residents and staff well being. Evidence was provided that outstanding requirement regarding the Legionella tests are being done to minimise the risk to residents. This is now considered met. St Martins Care Home DS0000002217.V329128.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 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 St Martins Care Home DS0000002217.V329128.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 15(1) Requirement Timescale for action 31/03/07 2 OP7 15(1) 3 OP7 15(2)(c) The registered person shall not provide accommodation to a resident at the care home unless, so far as it shall have been practicable to do so the registered person has obtained a copy of the assessment and so far as it shall have been practicable to do so there has been appropriate consultation regarding the assessment with the resident or a representative of the resident. Information from assessments that is pertinent to the care of the resident must appear on residents care plans. The Registered Person shall 31/03/07 prepare a written plan (the residents plan) as to how the resident’s needs in respect of his health and welfare are to be met. Care plans must show how residents’ needs are to be met. The registered person shall 31/03/07 where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the resident or a representative of his, revise the
DS0000002217.V329128.R01.S.doc Version 5.2 St Martins Care Home Page 25 4 OP9 13(2) 5 OP30 18(1)(c) resident’s plan. Residents or their representative must be consulted when creating or reviewing their care plans. The registered person shall make 27/02/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Improvements must be made in checking that medication coming into the home is correct. The registered person shall, 01/04/07 having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform. Staff who are working with people with dementia must receive up to date training on best practice. The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home. The registered person must ensure that the quality system established is used to monitor the quality and used to improve the service. 01/04/07 6 OP33 24(1) (a)(b) St Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 26 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 OP8 OP12 OP14 OP16 Good Practice Recommendations Where residents are identified as having or are at risk of developing pressure sores care plans must be created to show how this need is to be met. The registered person should develop a method to record all activities that take place in the home and who participate. The Registered Person should enable residents to access advocate services. The registered person should follow the homes procedures for complaints and create a record for capturing information regarding all comments and complaints made regarding the home. Where applicants have acted as reference for each other the registered person must ensure that he is satisfied that these are suitable. The registered person should make a record of each supervision meeting with staff. 5 6 OP29 OP36 St Martins Care Home DS0000002217.V329128.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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
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