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Inspection on 05/10/05 for St Martins Residential Home

Also see our care home review for St Martins Residential Home for more information

This inspection was carried out on 5th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

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

St Martins provides care for people with mental health problems in a relaxed atmosphere. Residents say that they enjoy the food and the easygoing relationship which they have with the staff. Staff are well trained and the home is near to achieving 50% of qualified care staff. The administration of medication is properly organised and recorded.

What has improved since the last inspection?

The home`s programme of NVQ training has continued and a staff supervision programme has begun. New comfortable leather sofas have been provided in the TV lounge.

What the care home could do better:

CARE HOME ADULTS 18-65 St Martins Residential Home 63 Martins Lane Wallasey Wirral CH44 1BG Lead Inspector Peter Cresswell Unannounced Inspection 5th October 2005 9:00 St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 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 Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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 Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Martins Residential Home Address 63 Martins Lane Wallasey Wirral CH44 1BG 0151 639 9877 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) Assistwide Limited Mr David Swift Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One (1) named female service user aged over 65 years (MD/E) within an overall total of 16 MD 24th January 2005 Date of last inspection Brief Description of the Service: St Martins Care Home is situated in a residential area of Wallasey, close to Liscard Village. It is a substantial detached property with two floors and a number of internal changes of level. The home would not be suitable for an independent wheelchair user. St Martins is not identified as a care home other than by its size, and blends in with the surrounding buildings. There are twelve single bedrooms and two that can be shared if residents so wish. The home has a dining room, lounge, and a spacious conservatory which overlooks the large garden. Shops, a post office, pubs, restaurants and other community facilities and bus routes are available in Liscard Village which is a short walk from St Martins. The Registered Person owns another similar home nearby. St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The lead inspector was assisted by a second inspector, Andrea Morris. The inspectors spoke to most of the residents, the manager and the senior carer who was on duty at the time. They toured the home, examined medication administration and a range of documents, including residents’ files, staff recruitment files, fire safety records and the accident book. What the service does well: 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. St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4, 5. Residents are only admitted if their needs have been assessed but this is not always adequately recorded. Individual contracts are in place to protect the rights and interests of the residents. EVIDENCE: Before a resident is admitted to the home the Registered Manager obtains a copy of the assessment made either by the hospital or the local authority social worker and these documents are kept on file. The file for one newly admitted resident had minimal details of an assessment by the Registered Manager. Most of the information relating to this person was still at his previous home (owned by the same Registered Person). Prospective residents are encouraged to visit the home and, if they wish, stay overnight before they make a final decision. Residents have individual contracts with the home and these are also kept on file. St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9. Care plans are inadequate and need to be compiled to ensure that up to date, accessible information and guidance is available to staff responsible for residents’ day to day care. EVIDENCE: There is a lot of information in individual residents’ files about their history and needs, including Care Management Assessments. The Registered Manager has also drawn up useful pen pictures for each resident. However, although many elements of a care plan are in place they have not been drawn together into a single plan which can be used as a practical guide by care staff and be approved by the resident. The last two inspection reports state that work has been going on to develop care plans and it is important that this is now carried forward rapidly. The inspectors discussed with the Registered Manager how care plans can be drawn up, how they can be linked to the daily reports and where he can get further advice and information. Regulation 6 describes the minimum requirements for a care plan (the ‘service user’s plan’) which must set out ‘how the service user’s needs in respect of his health and welfare are to be met’. Further guidance is in National Minimum Standards 2 and 6. Residents are encouraged to live as independently as possible and all of those who spoke to the inspectors said that they go out of the home on their own. St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 9 The home has a policy of restricting smoking to the conservatory. This was agreed by the residents at a meeting but is evidently not always observed in residents’ bedrooms. When the care plans are prepared they should include a section on the resident’s independence and decision making capacity. Most residents manage their own personal allowance. Residents are encouraged to take responsible risks, in accordance with their needs and capabilities and some risk assessments were on file. St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Daily routines St Martins are relaxed and residents take part in everyday activities in the community. Most residents enjoy the meals in the home and feel that they meet their dietary needs. EVIDENCE: Residents take part in a variety of activities. Several attend local day and drop in centres and most described to the inspectors how they visit local shops or travel to visit family and friends. The home also arranges some activities including trips out (a recent one being to Southport) and the residents were looking forward to a forthcoming trip to Blackpool Illuminations. The Registered Manager said that he is considering introducing some more individualised activities, such as taking groups for a pub lunch. The appointment of a part time activities organiser would enable a sharper focus on the organisation and individual tailoring of activities. The manager said that the Registered Person is considering the purchase of a vehicle for the use of residents at St Martins and its nearby sister home. Most residents said that they enjoyed the food in the home. Lunch is usually a light meal and the main meal is served in the late afternoon, usually round St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 11 about 4.30 pm. The Registered Manager said that this suits the residents, who have no doubt got used to the arrangement. However, it would be sensible to discuss the timing of the evening meal at a residents meeting to confirm if that time does in act suit them. Residents who want to eat later can of course do so and staff would heat up their meal. The menu is evidently to the tastes of the residents, who can have an alternative to the main meal if they so wish, though no choice is listed on the menu. The meal for the day is displayed on a whiteboard outside the kitchen. Some residents have a cooked breakfast and those who have cereals can prepare their own breakfast. In mid afternoon a member of staff was preparing cheese on toast for a number of the residents. St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Residents have access to all necessary heath services and medication is well organised, protecting the health and welfare of residents. EVIDENCE: Most of the residents do not need help with personal care tasks but staff described how those who do are given such care discreetly. The Registered Manager said that he is in the early stages of developing a keyworking system, as recommended in the last report. The scheme is in its infancy and will be assessed more fully at the next inspection. Information on personal care is contained in residents’ files but needs to be included in the care plans that the Registered Manager is about to put in place. Residents have access to community and specialist health care services as required and many receive support from a Community Psychiatric Nurse. Medication is well organised and safely stored, with most tablets being dispensed by the pharmacist in NOMAD plastic cassettes. Records for three residents were checked and were in order. Several residents receive medication which is to be administered ‘as required’ though it is not recorded how staff are to decide when it may be required. This is not uncommon, as it is rarely included on prescriptions. The Registered Manager agreed that it might be helpful to include this information on the residents’ records. Some medication had been included on the Medication Administration Record sheets St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 13 by the pharmacist despite having been discontinued by the GP. The MAR sheets should be amended and countersigned in these circumstances and the Registered Manager did so whilst the inspectors were present. The home does not keep homely remedies and did not have any controlled drugs at the time of the inspection though an appropriate cabinet is available if necessary. St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home has a satisfactory complaints procedure which residents can use to make their views heard. EVIDENCE: St Martins has a complaints procedure that includes details of how to contact the Commission for Social Care Inspection. There have been no complaints since the last inspection. The Registered Manager has a copy of the Wirral Adult Protection Procedures and staff receive training in the Protection Of Vulnerable Adults. St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30. The home provides reasonably furnished accommodation but some attention is needed to some décor and cleanliness in order to fully meet the needs of the residents. EVIDENCE: St Martin’s is in a residential area near to Liscard Village where there are shops and other local facilities for the community, including a post office. The home blends in with the other buildings in the area and the senior care assistant said that relationships with the neighbours are good. The home has a dining room, TV lounge and conservatory, which is also the smoking area and is therefore well used. During this unannounced inspection the communal areas were very well used. New, comfortable leather sofas have been bought for the lounge since the last inspection. The television from the main lounge is broken and has been temporarily replaced by a small set loaned from one of the residents. The Registered Manager said that a new set will be purchased if the old one cannot be repaired. The conservatory overlooks a large, reasonably wellmaintained garden which residents say they use in warmer weather. The communal areas were clean and well maintained. All residents have single bedrooms apart from one couple who had decided to share a room. There is a redecoration schedule for the bedrooms and one of St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 16 them was being repainted by the handyman during the inspection. The standard of bedrooms varies widely. One in particular was discussed with the Registered Manager, as the standards of cleanliness were very poor indeed. The Registered Manager said that this was due to the mental health of the resident, who resisted attempts to keep the room tidy and clean, though this did not in the opinion of the inspectors entirely explain the situation (for instance stained pillows). This needs to be fully set out in the care plan, as must a strategy for seeking to improve the standard of cleanliness in the room. The issue should be raised via a multi disciplinary case conference if necessary. Some new bed linen has been bought but the standard in a number of rooms was still inadequate. Beds are changed once a week but this was evidently not sufficient in several rooms, where the sheets needed to be washed. Many of the bedrooms reflect the personalities and interests of the residents, though some were rather bleak. All of the bedrooms have locks fitted and the security snips have been removed to enable access in an emergency. Although some old mortice locks are fitted they are not used and no keys are kept in the home. Alarm call points are fitted in each bedroom. The home has sufficient bathrooms and toilets but as pointed out in previous reports, residents might benefit from a walk in shower on the ground floor. The water delivered to the bathrooms was excessively hot and the temperature is controlled at the boiler. Water should be provided at a temperature close to 43C and this may be best achieved by fitting thermostats. Some furnishing and redecoration is required. The furniture in some rooms is rather old and in some cases damaged. In particular the chair and table in room 10 and the dressing table in room 5 need to be repaired or replaced. The Registered Person should review the quality of furniture in all bedrooms, as the inspectors were not able on this occasion to inspect every room. Some of the carpets are approaching the stage where they may need to be replaced. The bowl of the toilet near to room is cracked and must be replaced. The wallpaper and plaster in room 10 and the toilet near room 7 is damaged and should be replaced. The toilet near room 7 has an internal hook and eye lock which would make it unopenable in an emergency; this needs to be replaced by a suitable lock. St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Sufficient staff are employed to meet the needs of the residents. However, St Martin’s current recruitment procedures are inadequate and potentially leave residents at risk. EVIDENCE: Eleven care staff are employed, three of whom have at least NVQ2. Four more are currently studying for NVQ2 and three are due to start in January 2006. New staff receive TOPSS induction training and the Registered Manager shows a commendable commitment to staff training. Recent training has included Moving and Handling, First Aid, POVA, Administration of Medication and basic First Aid. Three staff have done a course on Adult Abuse run by the mental health charity MIND. The home is adequately staffed, with two care staff on duty at all times as well as domestic staff and a handyman shared with the nearby sister home. Two staff have been recruited since the last inspection and the home did not have either a CRB (Criminal Records Bureau) certificate or POVA (Protection Of Vulnerable Adults) clearance for them. This is unacceptable. Staff must have a CRB certificate obtained by the home before starting work. If staffing would otherwise fall below acceptable levels, then staff may start with POVAFirst clearance only, pending a full CRB certificate. In these circumstances staff may work under close supervision. Only one reference was on file for one of the new members of staff and none at all for the other. The Registered St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 18 Manager assured the inspector that references were being sought, though this was not evident from the file. These documents are required by the Care Homes Regulations 2001 and it essential that the home’s recruitment procedures are tightened up as a matter of urgency. The Registered Manager has introduced a programme of staff supervision, with supervision sessions taking place every two months. St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 St Martins does not have a quality assurance system, so there is no development plan to improve the home to enhance the residents’ quality of life. The home has appropriate safety policies and procedures but action is needed in respect of the recording of fridge and freezer temperatures to ensure the safety of residents. EVIDENCE: The Registered Manager has an NVQ4 and has managed the home for nearly three years. He says he has an ‘open door’ policy as far as staff and residents are concerned and there was an easygoing and friendly atmosphere in the home during the inspection. The relationship between staff and residents was relaxed and informal, which is a credit to the manager and his staff. St Martins does not have a quality assurance system, though the views of residents are gathered at meetings. The inspectors discussed with the Registered Manager ways in which a QA system could be put in place, including the use of questionnaires to provide feedback which can be fed into the periodic reviews required by the Care Homes Regulations. The Registered Person visits the home and prepares reports to meet the requirements of St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 20 Regulation 26 but the reports are not made monthly as required. This has been a requirement of the last two inspection reports. The Registered Manager said that recently the visits have been less frequent due to illness but they can be carried out on the Registered Person’s behalf. The kitchen was clean and well organised, with food stocks regularly rotated and checked. Fridge and freezer temperatures were checked and recorded but there were some long gaps in the recording. Temperatures must be checked and recorded every day. Fire safety records and safety certificates were up to date. One fire door was propped open during the inspection and the wooden door wedge was clearly kept there for that specific purpose. If fire doors are propped open they do not serve the function of preventing the spread of fire and smoke. Fire doors must be kept shut at all times unless they are held open by an approved device which releases them in the event of an alarm. Small electrical appliances have been checked by the home’s handyman and it would be good practice to record this centrally as well as on the appliance itself. As described earlier, the water delivered to the bathrooms was excessively hot. The Registered Person needs to take action to ensure that water is provided at a temperature close to 43C. In the meantime risk assessments should be carried out and cautionary notices posted. All radiators are properly guarded. Accidents are properly recorded but to meet the Data Protection Act the individual reports should be removed from the book and filed separately. St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 1 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Martins Residential Home Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 2 X X 2 X DS0000018941.V256396.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA3 Regulation 14 Requirement The Registered Person must ensure that residents are only admitted to the home following a full and up to date assessment of their needs. (Original timescale of 24 January 2005 not met) The Registered Person must prepare for each resident a care plan (the ‘service user’s plan’) setting out how their needs are to be met. (Original timescale of 24 February 2005 not met.) The Registered Person must keep the home clean and must therefore review the arrangements for cleaning the identified room and for the laundering of bed linen. The Registered Person must provide adequate furniture and bedding and must therefore: *review the quality of bedding in all rooms and replace that which is inadequate. *repair or replace furniture in the identified bedrooms. The Registered Person must keep the home in a good state of DS0000018941.V256396.R01.S.doc Timescale for action 01/01/06 1 YA6 15 01/01/06 2 YA24 23(2) 01/11/05 3 YA26 16(c) 01/01/06 4 YA21 23(2) 01/01/06 St Martins Residential Home Version 5.0 Page 23 5 YA34 19 6 YA38 13(4) 7 YA39 24 8 YA39 26 repair and must therefore: *replace the cracked toilet bowl in the identified toilet. * replace or make good the wallpaper in the identified toilet and bedroom. The Registered Person must not employ a person to work at the care home unless they are fit to be so employed and have a CRB certificate obtained by the Registered Person or, in the circumstances set out in this report, a POVA First check. The Registered Person must also obtain two references for each employee. (Original timescale of 24 January 2005 not met) The Registered Person must eliminate risks to the safety of residents and must therefore ensure that: *hot water is supplied at a safe temperature. *fridge and freezer temperatures are checked and recorded daily. *fire doors are not propped open unless they are fitted with a suitable self-closing device. * the hook and eye lock to the identified toilet is replaced with a lock that can be opened from the outside in an emergency. The Registered Person shall establish a system for reviewing the quality of care provided at the home. The Registered Person must ensure that Regulation 26 monitoring visits and reports are undertaken each month and forwarded to the Commission for Social Care Inspection. Any reports prepared must comply with and include all aspects of Regulation 26 (4). 05/10/05 01/11/05 01/02/06 01/11/06 St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 24 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 Refer to Standard YA14 YA24 YA42 Good Practice Recommendations The Registered Person should consider the appointment of a person to organise activities for residents. The registered person should submit a programme of redecoration and replacement of fabric and furniture to the Commission for Social Care Inspection. Information on accidents recorded in the Accident Book should be retained in a form which ensures the confidentiality of the people concerned and complies with the Data Protection Act. St Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Martins Residential Home DS0000018941.V256396.R01.S.doc Version 5.0 Page 26 - 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. 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