Inspection on 30/10/07 for St Marys Care Home

This inspection was carried out on 30th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 Marys Care Home 10/02/09

St Marys Care Home 18/09/08

St Marys Care Home 19/06/08

St Marys Care Home 20/02/07

St Marys Care Home 15/06/06

St Marys Care Home 24/01/06

St Marys Care Home 14/11/05

St Marys Care Home 09/02/05

St Marys Care Home 21/09/04

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

CARE HOMES FOR OLDER PEOPLE St Marys Care Home The Old Vicarage Main Street Blidworth Nottinghamshire NG21 0HQ Lead Inspector Karmon Hawley Key Unannounced Inspection 30th October 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Marys Care Home DS0000008816.V350944.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 Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Marys Care Home Address The Old Vicarage Main Street Blidworth Nottinghamshire NG21 0HQ 01623 795231 01623 795231 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) Broadoak Group of Care Homes Vacant Care Home 23 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (23), Old age, not falling within any other of places category (22) St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered to provide personal care for service users of both sexes Whose primary needs fall within the following categories Old age, not falling with in any other category (OP) (23) Dementia - Over 65 years of Age (DE[E]) (23) Date of last inspection 20th February 2007 Brief Description of the Service: St Marys Care home provides personal care and accommodation for 23 older people. At the time of inspection 19 residents were accommodated at the home. St Mary’s Care home is owned by the Broadoak Group that is a company which provides care for older people in Nottinghamshire and some of the surrounding counties. St Marys is a large converted vicarage situated on the main road in the village of Blidworth Nottinghamshire, fairly close to local amenities. All the bedrooms are furnished in a similar style and well appointed, many of these are well personalised. Six of the bedrooms have en-suite facilities. Most of the rooms have views over the rolling countryside. The lounge areas are situated on the ground floor of the home both lounge areas overlook the garden areas. Car parking is available. The current weekly fees range from £290 - £344 per week depending upon individual needs, these do not include hairdressing and chiropody fees. This information is made available on the point of enquiry. St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken by an inspector reviewing all the previous inspection records available, looking at information provided by the manager about St Mary’s Care Home and by undertaking a visit to the service with the inspector using a method called “case tracking.” “Case tracking” involves identifying individual service users who currently live at the home and tracking the experience of the care and support they have received during the time they have lived there. The inspector also checked that information provided by the manager matched individual experiences of the service user living at the home by talking with them and observing the care received. General records maintained by the home were looked at to ensure these were maintained and provided positive outcomes for service users. What the service does well: What has improved since the last inspection? Handwritten entries on medication records are now signed by two members of staff to show that these have been checked as correct. Documentary evidence is now available to demonstrate that further activites are on offer for service users to enjoy. Further staff have enrolled on the National Vocational Qualification (a nationally recognised work and theory based qualification) thus enhancing their skills and knowledge. Attention in regard to the hot water system has taken place to ensure that service users are protected from scalds. St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Marys Care Home DS0000008816.V350944.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 Marys Care Home DS0000008816.V350944.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are assured that their needs will be assessed and that staff can meet these before they make a decision to move into the home. The service does not offer intermediate care. EVIDENCE: A member of staff visits prospective service users in the community to carry out a preadmission assessment to ensure that the staff are able to meet service users needs before they are admitted to the home. Prospective service users and relatives may also visit the home and spend time there before making a decision to move in to the home. Within those files observed there was evidence of the assessments taking place and staff obtaining referral assessments from the social worker if appropriate. Staff spoken with were able to discuss the preadmission procedure and they discussed how people may come and have a look around if they want. The acting manager was observed to liaise with a prospective service user’s relative and offer them the opportunity to visit the home. St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 9 The service does not offer intermediate care. St Marys Care Home DS0000008816.V350944.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. As information gained within initial assessments is not fully utilised, service users needs are not fully met, as appropriate plans of care are not in place. Service users remain at a degree of risk due to the lack of risk management plans in place to protect them. EVIDENCE: Service users undergo various assessments such as the activities of daily living, manual handling and the risk of developing pressure sores. Plans of care are then based upon these findings. However within one case file where a risk of developing pressure sores had been highlighted, there was no plan of care in place to monitor this or reduce the risk to the service user. Plans of care gave dates when reviews had taken place, these simply stated ‘no changes’ for several months, whereas significant changes had occurred in regard to one service user, this had not been highlighted in the review. Therefore the plan of care was not up to date and consequently did not reflect the level of care or support they needed. Risk assessments and plans of care in regard to service users who may wander and attempt to leave the building were in depth and outlined the level of St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 11 support service users needed. However there were no risk management plans in place for the risk of entrapment when using bedrails, or for those service users who have diabetes mellitus, thus leaving service users at a degree of risk should complications occur. Within plans of care it stated that staff should offer service users stimulation of the mind and provide effective and meaningful interaction, it did not state how staff would accomplish this to ensure that it was a positive experience for service users. Daily records were maintained, these were in depth and contained all the required information about the care service users had been offered and any changes in their condition; however this vital information had not been utilised within the plan of care. Staff spoken with were able to discuss service users individual needs. Service users spoken with spoke highly of the staff and the care they received. There was evidence within service users files to show that they receive support and assistance from services such as the district nurse, doctor and optician when needed. The acting manager said that there are good relations with the district nurses as they visit the home on a regular basis and they ensure that service users receive the necessary equipment that they require. During the brief tour of the home equipment such as specialist mattresses were seen. One service user spoken with said that they can see the doctor if they need to. Medication checked on the day of the visit corresponded with service users medication records. All handwritten entries had been signed by two members of staff to show that these had been checked as correct. Medication issues are noted within service users plans of care, and on checking a service users case file, a change in their medication had been appropriately recorded. Three members of staff who administer medication have received training in this area, however as this was undertaken over four years ago the acting manager is looking at arranging an update. The acting manager said that staff are instructed on maintaining service users privacy and dignity at all times. There was reference to ensuring that this was maintained whilst staff assisted service users with their personal care in service users case files. Staff spoken with were able to discuss how they ensure that this is done by their work practices, such as knocking on doors and being mindful of service users personal choices and preferences. All service users spoken with expressed that staff were very kind and respectful. St Marys Care Home DS0000008816.V350944.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are facilitated to enjoy the activities available to them should they wish to join in. To ensure that service users continue to maintain meaningful relationships, visitors are always made welcome in the home. EVIDENCE: A care assistant now offers an hour of activities on each of their allocated shifts. Activities such as dominoes, skittles, sing a longs and arts and crafts are available both on a group and individual basis. During the visit a group of service users were observed to enjoy a game of dominoes and others played on the organ. Staff were observed to support service users in a positive manner throughout and service users interacted with each other during this time. Service users spoken with expressed that they enjoyed the activities on offer and looked forward to them. One service user spoken with discussed how they were looking forward to the bonfire night party. Staff spoken with were positive in regard to ensuring that service users receive an adequate amount of stimulation. The person who is responsible for activities discussed the further developments they have in mind to offer a wider range of activities. Staff stated that the routine of the home was flexible and service users were St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 13 observed throughout the visit to walk freely around the home and entertain themselves if they wished. To ensure that service users are able to maintain relationships that are important to them there are no restrictions placed upon visiting and visitors may be received in private should they wish. Two service users spoken with said that they enjoy having visitors and staff make them feel welcome. One said that they can see their visitors in private should they wish. Staff spoken with were able to discuss service users individual needs and the support they required in meeting these. Although plans of care were not indepth with regards to a service users past life experiences, it was evident when observing staff and service user interaction that staff have a good understanding of these. The acting manager is currently looking into arranging further links with the community and the local churches to enable service users to participate in this if they wish. A wholesome and appealing menu was on offer with choices available at each meal. Service users spoken with said, “food is very good, I get plenty to eat”, “I enjoy my food, they have things I like” and “ the food is very nice, I can have a choice.” Staff were observed to assist service users during the lunchtime meal in an appropriate manner. St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although service users feel that staff listen to their concerns, complaints are not dealt with effectively to ensure that these are fully resolved and that staff learn from these to ensure they do not reoccur. Service users are not fully protected from abuse. EVIDENCE: There have been two complaints made to the Commission since the previous inspection, one of which was referred back to the provider to investigate. The acting manager said that she had also received a complaint within the last month and had acted upon this. There were no records available of complaints received or how these had been dealt with, therefore offering no evidence that these had been dealt with effectively and appropriately. Staff spoken with were able to discuss how they would deal with a compliant should one be received. All service users spoken with expressed that they were happy with life within the home and the care they received. One service user said, “staff are very nice, they have time for me and listen if I am worried about anything.” All staff with the exception of one have a satisfactory Criminal Record Bureau check in place (a police check to see if an individual has a police caution or criminal record). The other member of staff had a POVA 1st in place, (a check made to see if an individual has been place on a register which identifies that they have abused a vulnerable person.) On observing the duty rota it was not clear how this person was being supervised, the acting manager said that staff always work together, however on observing the duty rota this person was St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 15 highlighted as going on escort with a service user, this would result in them not being supervised by another member of staff. There was no supervisory practice policy in place so that staff were aware of their responsibilities when supervising staff who only have a POVA 1st nor a policy for the supervisee to ensure they were aware of the restrictions imposed upon them. When observing four staff files there was evidence to show that one member of staff has had training in the safeguarding of adults. Without observing all files there was no system in place to offer an overall picture of the training staff had achieved. On speaking with a member of staff they stated that they had not received training in this area, however they were able to discuss what they felt constituted abuse and how they would respond should they suspect that abuse was occurring. However in regard to the understanding of abuse occuring between service users and the necessity to report the incidents to the safeguarding team, knowledge was minimal and this had not taken place following an incident, nor had this been recorded appropriately within service users plans of care. St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable and homely environment. EVIDENCE: Ongoing maintenance continues and the maintenance person was working at the home on the day of the visit installing security alarms to the fire exits. This work was being undertaken to alert staff if those service users who wander attempt to leave the building. There was evidence available within the maintenance book to show that repairs are carried out as needed. The home was well maintained and comfortable homely furniture was in place. New sinks and taps have been installed in service users rooms and a number of rooms have also been redecorated offering a comfortable and well-maintained environment for service users. Temperature values have been installed to regulate the temperature of the water delivery to protected service users from scalds. St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 17 All areas of the home accessed were clean and tidy, one service user spoken with said that they had brought their own things into the home and staff looked after these and kept their room nice and clean. Appropriate hand washing equipment was available to reduce the risk of infection. St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 18 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 are adequate. This judgement has been made using available evidence including a visit to this service. The current recruitment policies and procedures in place do not fully protect service users. Although staff are undertaking some training further is needed to ensure that all staff have the required knowledge and skills in compulsory areas, thus ensuring that service users needs are fully met. EVIDENCE: The duty rota observed showed that there is two care staff on each shift, and on occasion in addition to this the manager works on a supernumerary basis. Staff spoken with said that the staff team worked well together and that the majority of the time sufficient staff were available to meet service users needs, however they stated that it was very busy in the early part of the morning whilst assisting service users to rise when there were also other duties to perform. Service users spoken with said, “staff are there when I need them to help me,” and “staff are very good, they help me when I need it to make sure that I am ok.” Throughout the visit staff were observed to interact with service users and assist them as needed. The acting manager now ensures that all new staff undergo an induction to ensure that they are aware of their roles and responsibilities and the needs of service users. One member of staff discussed the initial training they had received when they first joined the home; they felt that the staff team were very supportive and friendly. Eight members of staff have attained the National St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 19 Vocational Qualification (a nationally recognised work and theory based qualification) level two or above. This covers training in all areas relating to the service user group to ensure staff have a good knowledge and understanding of service users needs. Evidence was also seen to show that a further two members of staff will be commencing on this training soon. One member of staff spoken with confirmed that they were due to start this training. To ascertain if a thorough recruitment process was in place, four staff personnel files were observed. There were insufficient references available for three members of staff. The acting manager is currently auditing staff files to ensure that all have the required documentation in place to ensure that service users are protected. There was evidence of this occurring within three of the files seen. Within staff personnel files there is a record of staff training. There was evidence that staff had undertaken training in health and safety, fire, and manual handling, however there were deficits in safeguarding adults and first aid. Although the cooks have basic food hygiene certificates there was no evidence to show that care staff have undertaken any training in this area to protect service users when staff are handing out meals and assisting service users to eat. Four members of staff have undertaken training in dementia care, however the remaining have not. Staff were observed to understand service users needs and there was evidence of good relationships between staff and service users. Staff spoken with were able to discuss service users needs and the help and support they offered them to meet these. St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 20 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ need to be given more formal opportunities to express their views and opinions about the service, so that these views are listened to and fully considered in the quality monitoring of the service. Service users personal allowances are not fully protected due to the current systems in place. EVIDENCE: The acting manager has now been in post for one month. She has nursing experience and has been a deputy manager of a care home in the past. She is intending to enrol on the Registered Managers Award. This qualification makes sure that managers have the skills, which they need to manage a care home. She spoke of the development plans she has in mind for the service, to enhance the quality of care service users receive. She stated that she has already made progress such as arranging further training for staff, auditing St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 21 care plans and staff files and introducing more activities and stimulation for service users. Staff spoken with spoke highly of the manager and said that she was friendly and approachable. The provider visits the home on a monthly basis and completes a report of their findings, a copy of this is sent to the Commission for Social Care Inspection to enable them to monitor the service. There are quality assurance policies in place, which state that service users are given annual questionnaires to complete, however there was no evidence available to demonstrate that this takes place. Service users are able to have money kept in the homes safe should they require this service; the acting manager said that most service users use this facility due to their current needs. Three service users accounts were checked, two were correct whereas one showed a deficit. There was no evidence available to show that these are audited on a regular basis. The acting manager said that service users could access their money at any time. All members of staff have undertaken training in health and safety and were observed to follow good practice throughout the visit. Staff spoken with were able to discuss health and safety issues. Water temperatures are now recorded on a monthly basis and monitoring values have been installed to protect service users from scalds. Alarms have been placed on the exit doors to enable staff to be aware should a service user who requires supervision attempt to leave the building. St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 22 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 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 1 17 X 18 1 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 2 X 2 X 2 X X 3 St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? 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 OP7 Regulation 13(4,c) Requirement Systems must be in place to ensure risk management plans are in place for all highlighted risks to ensure that service users are fully protected. This is an outstanding requirement since 16/07/06 and must be addressed. Service users reviews are required to be service user focussed in order to reflect their care and condition, thus enhancing the continuity of care received. This is an outstanding requirement since 16/08/07 and must be addressed. 4 To demonstrate that complaints are being dealt with appropriately and effectively, a written record of complaints received by the service must be available for the Commission for Social Care Inspection on request. Measures must be put into place to ensure that service users are protected from the risk of harm or abuse to ensure that they are DS0000008816.V350944.R01.S.doc Timescale for action 27/11/07 2. OP7 15(1,b) 27/11/07 3. OP16 22(8) 15/12/07 4 OP18 13(6) 27/11/07 St Marys Care Home Version 5.2 Page 24 5 OP18 18(2) 6 OP29 19(1,b,i) schedule 2 18(1,c) 7 OP30 8 OP31 8(2) 9 OP33 24(1) 10 OP35 17(2) schedule 4 fully protected. Systems must be in place to ensure that those staff working with a POVA 1st in place must be adequately supervised to ensure that service users are protected. All the necessary documentation must be obtained before a person is employed by the home to ensure that service users are fully protected. Systems must be put into place to ensure that all staff have undertaken compulsory training to ensure that they have the necessary knowledge and skills to meet service users needs. The registered person shall give notice to the Commission the name of the person appointed as the acting manager and the intention to register this person as the registered manager, to ensure that service users live in a home that is well run and managed. Systems must be in place to ensure that service users have a formal method of ensuring that their views and opinions are listened to and taken into consideration in the running of the service. An accurate record of all money deposited by a service user or their relative must be kept to ensure that service users personal finances are protected. 28/11/07 28/11/07 28/01/08 15/12/07 15/12/07 28/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 25 No. 1. 2. Refer to Standard OP12 OP30 Good Practice Recommendations Develop further community links. Develop a staff training matrix to clearly demonstrate training that all staff have undertaken. St Marys Care Home DS0000008816.V350944.R01.S.doc Version 5.2 Page 26 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 © 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 Marys Care Home DS0000008816.V350944.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. 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