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Inspection on 06/06/06 for St Marys Nursing Home

Also see our care home review for St Marys Nursing Home for more information

This inspection was carried out on 6th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

What the care home does well

The home has a friendly and welcoming atmosphere. There is a flexible visiting policy which enables families to visit their loved one as best suits them. Care plans were written to a good standard, clearly generated by the results of risk assessments. They included clear and detailed instructions to follow when carrying out care, and included detail of personal choices and goals. The activities plan includes a wide variety of choice. This includes more traditional groups such as bingo and dominoes, individual reminiscence sessions, hand/nail care, religious worship sessions, outside agencies coming in and is presently working on a sensory garden project. Service users are encouraged to make suggestions and voice their opinions about all aspects of their care, through a monthly service user meeting.Service users and their representatives where appropriate, are involved in the review of individual care packages. One representative said "I m always kept very well informed about mums care". Clear records are kept of any complaints and steps taken through the investigation process. There is a comment box and comment slips in the reception area ensuring that everyone who comes into the home has the opportunity to make their opinions known.

What has improved since the last inspection?

The home has made great progress in replacing the old beds for new adjustable ones. It is recognised that this is an expensive operation and will be completed over a reasonable period of time. There is a signing in book in reception, and all staff are aware that visitors to the home must identify themselves, sign in and address a member of staff for assistance. The staff appeared enthusiastic and are reacting in a positive way to the changes that have been implemented since BUPA bought the home. Staff are happy and comfortable with their new uniforms, and feel well supported.

What the care home could do better:

All staff must ensure that when administering medication the policy is fully adhered to and records are completed appropriately. The home should consider that not all service users are happy to have bedroom doors and curtains open when they are trying to sleep. The home should consider alternative ways of carrying out the early morning hand over which is presently done between two nurses whilst touring the home. This means that a breach of confidentiality is likely to occur.

CARE HOMES FOR OLDER PEOPLE St Marys Nursing Home 19 Dunstable Road Luton Bedfordshire LU1 1BE Lead Inspector Mrs Louise Trainor Unannounced Inspection 6th June 2006 06:45 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 Nursing Home DS0000017693.V290225.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 Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Marys Nursing Home Address 19 Dunstable Road Luton Bedfordshire LU1 1BE 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) 01582 438200 01582 484116 www.bupa.com BUPA Care Homes (CFHCare) Limited Vacant Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60) of places St Marys Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home can accommodate a maximum of 60 service users of either sex. OP 60. Service users admitted prior to 01/06/05 may have a diagnosis of dementia. Up to 10 service users can be admitted under the age of 65. Date of last inspection 23rd November 2005 Brief Description of the Service: St Mary’s Care Home is a purpose built nursing home situated in central Luton on the site of an old hospital. The home provides single bedroom accommodation for service users over the age of 65years. The original building has been extended to provide 60 bedrooms on two floors accessed by a shaft lift. There is an open courtyard area with seating where in the summer plants provide interest and colour. The bedrooms are varied; some in the older part of the building have retained their original features. A number of communal rooms provide service users with a choice of seating areas. There is adequate staff and visitor car parking space. Staff are divided into two teams to deliver care, each team covering one floor. The staff teams are made up of qualified nurses, carers and senior carers supported by teams of housekeeping and administrative staff. Fees for this service start at £507.00 per week for Service Users funded by Social Services, and private rates start at £700.00 per week. These rates then vary depending on the individual needs required. St Marys Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Key Inspection for this service for this year. It was carried out by Lead Inspector Louise Trainor on the 6th of June 2006 between the hours of 06:45 hour and 16:45 hours. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the services provided. The process considers the home’s capacity to meet regulatory requirements and minimum standards of practice. During the inspection two service users were ‘case tracked’, this involved talking to the service users, observing their care and examining their personal files. In addition to this, two other service users were talked to at length, and two visitors were also informally interviewed. Various documentation relating to complaints, medication administration, recruitment and finances were also seen. The manager was present for most of the inspection and four other members of staff made themselves available for interview. Various care practices were observed during the day, and these included, the lunchtime meal and a medication round. A full tour of the premises took place on arrival at 06:45 hours, and some of the night staff on duty were briefly interviewed. The inspector would like to thank everyone involved for their assistance and support during the inspection. What the service does well: The home has a friendly and welcoming atmosphere. There is a flexible visiting policy which enables families to visit their loved one as best suits them. Care plans were written to a good standard, clearly generated by the results of risk assessments. They included clear and detailed instructions to follow when carrying out care, and included detail of personal choices and goals. The activities plan includes a wide variety of choice. This includes more traditional groups such as bingo and dominoes, individual reminiscence sessions, hand/nail care, religious worship sessions, outside agencies coming in and is presently working on a sensory garden project. Service users are encouraged to make suggestions and voice their opinions about all aspects of their care, through a monthly service user meeting. St Marys Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 Page 6 Service users and their representatives where appropriate, are involved in the review of individual care packages. One representative said “I m always kept very well informed about mums care”. Clear records are kept of any complaints and steps taken through the investigation process. There is a comment box and comment slips in the reception area ensuring that everyone who comes into the home has the opportunity to make their opinions known. 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 Marys Nursing Home DS0000017693.V290225.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 Nursing Home DS0000017693.V290225.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The admission process includes the consultation of assessment information, and service user/representative visits, to ensure service user’s individual needs will be met. There is a detailed Statement of Purpose which includes a Service User Guide, however not all service users presently have access to them. EVIDENCE: The Statement of Purpose and Service user Guide have just been rewritten following the take over of the home by BUPA earlier this year. Unfortunately these are still in the process of being distributed to the service users and placed in personal files. One relative who was visiting their mother confirmed she had had sufficient information about the home prior to admission, she also stated “we looked long and hard and saw so many grim places before we found this place. As soon as we walked in we knew this was the one”. St Marys Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 Page 9 The two service user files that were examined contained very detailed assessments that included personal preferences and choices. One detailed ‘Feels the cold, likes a duvet’. The other specified a language barrier. All privately funded service users have a signed contract of care that includes the fees of the home. However Social Service funded service users do not. This is because the contract is between the home and social services. There was documentation to indicate this. The home did not provide intermediate care St Marys Nursing Home DS0000017693.V290225.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. This service has clear detailed risk assessments and care plans in place to ensure all service users’ needs can be met fully. This process is complemented by the involvement of service users and their relatives when care is reviewed and updated. However poor compliance of the medications policy by some staff indicates that service users may not always be protected. EVIDENCE: The personal care plans that were seen in this home were of a very high standard. They had clearly been generated by the numerous risk assessments, and they gave very clear instruction of how the care should be carried out, ensuring continuity. They also incorporated preferences and choices of the service users. Care plans and risk assessments were all being reviewed regularly, and documentation was signed for consent and agreement. One of the files seen contained a ‘Map of Life’ that illustrated beautifully the service user as an individual, and this was then reflected in this individuals’ care plans. St Marys Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 Page 11 Individual service user files contained information to be addressed in the event of death. This included the individuals choices regarding burial / cremation and also undertakers. All records relating to the administration of medication were inspected. There was a declaration form with a sample of all qualified staff signatures at the front of the folder containing the MAR sheets. There was also a list of all acceptable ‘Homely Remedies’. Attached to each service user’s MAR sheet was a head and shoulder photograph. Three service users were presently prescribed controlled drugs. These were all appropriately signed for, and the number of tablets left corresponded to the number recorded. Nine of the service user charts that were examined had missing signatures on them. When the blister packs were checked, the tablets were missing from the corresponding sections of the pack, indicating that some staff are administering medication and not signing for them. Throughout the inspection service users were generally being treated in a dignified and respectful manner. However it was of some concern that when the inspector arrived at 06:45 hours and toured the premises, the majority of the service user’s bedroom doors were wide open and the majority of the bedroom curtains were opened and tied back, despite most of the service users still being asleep in bed. The early morning hand over was carried out, between two nurses whilst they wandered around the home. This could have been done in a better way that promoted service user confidentiality more effectively. Also, whilst talking to the daughter of one service user in her room, a nurse came in with the doctor and proceeded to examine the service user without asking either the inspector or the daughter to leave the room. The daughter did confirm that this was very unusual, and she would normally be asked to wait outside. She also emphasised that she was very satisfied with her mothers care and is always kept fully informed of any changes in her care. St Marys Nursing Home DS0000017693.V290225.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users have the confidence to discuss what makes them happy and comment where improvements can be made. The home takes residents feedback seriously and makes changes where possible. Staff listen to residents and make considerable effort to provide a flexible service, which enables them to enjoy a better quality of life. EVIDENCE: Throughout the inspection many service users were receiving visitors, some were in the day lounges, some in the privacy of their rooms and others in the garden. The atmosphere was friendly and welcoming throughout. The home has an activities organiser who works forty hours a week and has been in post for five years. From discussion with her, it was obvious that she is very passionate about the work she does. Her programme includes some traditional group activities such as bingo, cards and dominoes, but much of her time is spent doing 1:1 sessions, allowing service users to reminisce on a personal level, as well as doing activities such as nail and hand care. She has St Marys Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 Page 13 recently started work on a ‘sensory garden project’ with some of the service users, and children from a local school are also involved with this project. There are already plans in progress for a travelling pantomime group to come in at Christmas. On the day of the inspection there was a residents meeting held, where service users were given the opportunity to voice their ideas and opinions. Before it started, views were sought from those who were either unable to or did not wish to attend. One of the main topics from this meeting was the food. Although the four- week menu appeared to have a good daily choice, the day of the inspection was disappointing. The choices were, Fisherman’s Pie, Omelette or Sandwiches. There was no meat choice on the menu. During the mealtime on Willows Wing one service user did not eat her meal, she had been given fisherman’s pie despite not liking fish. She was heard to say “I ve never liked fish”. This indicated that a choice of meal was not offered prior to it being served. Meals were well presented. One service user representative commented on how her mother had a pureed diet, but it was always served in an appetising way, not all mixed together. The home has a Roman Catholic priest or Sister that visits once a month, and service users have the opportunity to receive Holy Communion. Also a Church of England service is held once a month on the premises for those who wish to attend. St Marys Nursing Home DS0000017693.V290225.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Policies and procedures relating to complaints and protection are robust and adhered to by staff. A clear understanding and awareness of these policies was demonstrated ensuring service users are protected. EVIDENCE: A monthly residents meeting is held, and service users have the opportunity to raise any concerns informally. In the last six months there had been three informal complaints relating to lost dentures, all made verbally, and two formal complaints. Both of the formal complaints had a clear record of: all steps taken during the investigations, all action required and taken, and the response to the service user/ complainant. The home’s induction programme includes awareness of Protection of Vulnerable Adults (POVA). In addition to this, one of the senior staff has completed the ‘train the trainer’ training for POVA. All staff that were interviewed were able to demonstrate clearly what action they would take if they suspected any kind of abuse. St Marys Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a wellmaintained environment, which provides aids and equipment to meet the care needs of the residents. It is a very pleasant, safe place to live, with individual rooms furnished with personal possessions. EVIDENCE: The home is a pleasant, well-maintained environment with pleasant gardens. The corridors were free from clutter and the home was generally clean and free from offensive odours. Bathrooms were well equipped with hoists. However they did appear rather clinical and could do with being brightened up and made more homely and inviting. There was evidence of moving and handling equipment being used competently during the visit. St Marys Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 Page 16 One service user who was visited in her room, stated she was comfortable and well looked after, although disappointed that this was ‘the only residue left from her five bedroom bungalow’. This lady spends most of her time in bed out of choice, as she cannot walk and refuses to go in the hoist. She has a pressure-relieving mattress on her bed, and was proud to show the inspector that the skin around her pressure areas was in perfect condition. Personal photographs that clearly meant a lot to her surrounded her. Her room looked out to a garden area and she had a bird feeder hanging at her window that gave her pleasure to watch. The home has recently replaced twelve old beds for new adjustable beds, leaving only fourteen old beds in the home. These will be replaced later in the year. St Marys Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The homes policies for the recruitment and training of staff are robust so that service users are protected. EVIDENCE: This home has a robust recruitment procedure. All staff files that were seen contained all the appropriate documents, and records of CRB/POVA/Nurse registration checks. All staff works through an induction programme that addresses: Health and Safety, food hygiene, abuse, whistle-blowing and individual responsibility. The four care staff that were interviewed during the day and all were quite enthusiastic about their jobs. All spoke highly of the support they received from the manager, the deputy manager and senior staff. One member of staff talked at length about one of the service users that the inspector had case tracked. This highlighted just how well some of the staff knew the service users. The home has a system whereby every day, at afternoon handover, one service user’s care plan is discussed with the whole team. This appears to be a very effective method of ensuring all staff have up to date knowledge and information about the people they care for. However when the inspector arrived at 06:45 hours, neither of the qualified nurses on duty were able to tell the inspector exactly how many service users they had in the home at that particular time. St Marys Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 Page 18 Three of the four staff spoke very positively about the changes and improved level of support since the ‘take over’ by BUPA, however one felt that she had noticed very few changes, and another stated “there are positive changes, but we are struggling with all the new paperwork”. Staff competencies are closely monitored by senior staff. Part of the deputy manager’s role is to work alongside the care staff every Tuesday enabling her to observe skills and practices, and identify where there maybe areas requiring more attention. Staff meetings are held monthly and the staff interviewed felt these were helpful in identifying where improvements were necessary. There is a training programme in place. This incorporates mandatory and optional training. There is presently two staff trained to deliver Moving and Handling training, and one to deliver POVA training. There is an in house training session held every Wednesday and the programme for this includes: catheter care, bowel management, cot side training, personal best and pressure area care. The home also has access to distance-learning courses in: diabetes, dementia care, infection control, food hygiene, health and safety and care of the elderly. Both of the care staff interviewed had just completed NVQ certificates and were looking forward to the next courses to begin. One of the qualified nurses interviewed had done training in: diabetes, respiratory infections and PEG feeds, is presently doing palliative care, and would like to do dementia studies. St Marys Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Policies and procedures are in place to promote the health, safety and welfare of service users, however all staff may not always adhere these to. EVIDENCE: The manager has only come in to this post since the last inspection, and is in the process of gathering the necessary paperwork to submit to CSCI for registration. However the home is presently running well, and both staff and service users indicated they had confidence in her. The manager has introduced monthly meetings for the service users. This enables her to hear their views, opinions and suggestions. St Marys Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 Page 20 All staff were able to discuss their supervision and identify who their supervisor was, and three had recently had an annual appraisal. Supervision records were viewed, and although not all staff are having supervision as regularly as they should, the manager, who has only taken up this role since the last inspection, is working hard to improve in this area. All service users have a deposit account, however there is a maximum of £100.00 immediate withdrawal. This is taken from a petty cash float of which is kept on site. For larger amounts, notice is required to withdraw it from the bank. If an immediate withdrawal is requested at the weekend, the staff must contact the manager for access. All account balances are monitored and recorded on the computer system. St Marys Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 1 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 2 2 2 X 2 St Marys Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 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 OP9 Regulation 17 Requirement Medication charts must be completed accurately, including the reverse of MAR sheets if this is necessary. This requirement is outstanding from the previous report – previous timescale 01/01/06 The manager must ensure that all staff recognise and promote the importance of privacy and dignity within the home. Adjustable beds must be provided for all service users. This requirement is partially unmet. Timescale for action 01/07/06 2. OP10 12(4)(a) 01/07/06 3. OP24 16 01/10/06 St Marys Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 Page 23 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. Refer to Standard OP24 OP10 Good Practice Recommendations All the bathrooms should be made ‘homely’ The home should consider alternative methods of carrying out the early morning hand over. St Marys Nursing Home DS0000017693.V290225.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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. 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