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Inspection on 24/08/07 for St Michael`s Care Home for the Elderly

Also see our care home review for St Michael`s Care Home for the Elderly for more information

This inspection was carried out on 24th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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.

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

Overall the staff on duty that aided the inspection process was observed to be good at their jobs and to be caring towards the residents who looked well cared for. Residents spoken with felt that they had confidence in the staff that supported them. The environment was clean, odour free and practical for the needs of the residents of St Michaels.

What has improved since the last inspection?

First Inspection since being registered April 2007

What the care home could do better:

Just recently the home has not had a registered manager in post. It was apparent throughout the inspection process that there is a lack of a leadership presence on a day-to-day basis. Many inspection records and documentation needed to evidence good and safe practices were not available.Additionally issues raised on the site inspection through surveys and other information collated about the home were unable to be discussed. These issues are important for the safety and protection of residents and management systems need to monitor that practices and procedures are being carried out appropriately. These issues are reflected in many of the areas throughout this document, as is the failure to meet some aspects of the Regulations and Care Standards.

CARE HOMES FOR OLDER PEOPLE St Michael`s Care Home for the Elderly 20 Meteor Road Westcliff On Sea Essex SS0 8DG Lead Inspector Sarah Hannington Unannounced Inspection 24th August 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Michael`s Care Home for the Elderly DS0000069721.V348088.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 Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Michael`s Care Home for the Elderly Address 20 Meteor Road Westcliff On Sea Essex SS0 8DG 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) 01702 354735 01702 301060 Kennethmgshpd@yahoo.co.uk Dr Kenneth Ihuoma Managers Post Vacant Care Home 8 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (8) of places St Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection First Inspection Brief Description of the Service: St Michaels Rest Home provides accommodation and care for eight older people with dementia. It is a small family style home. The lounge is situated at the front of the house and the dining room overlooks the garden, which is paved and has the use of tables and chairs. There is a bathroom situated on each floor and the use of either a shower or a bath. Toilet facilities are on both floors. The home offers six single bedrooms and one double, which have been separated to ensure privacy. Rooms vary in size, but none have ensuite facilities and some would be too small for wheelchair use. A shaft lift provides access to both floors where service users accommodation is provided. St Michaels Rest Home is close to local amenities, including transport facilities. There is limited parking on site but additional parking is available on Meteor Road. Weekly fees range from £335.16 to £416.85 depending on the care required. St Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit inspection mainly focused on all Key standards and this is the homes first inspection since being registered in April 2007. The inspection took 4 hours to complete. Prior to this inspection CSCI (Commission for Social Care Inspection) sent out surveys to all interested parties. Information collated from surveys and discussion during the site inspection will be reflected within this report. Additionally the proprietor was sent a (AQAA) Annual Quality Assurance Assessment form by CSCI (Commission for Social Care Inspection) that asked the priopritor how well the home is meeting the needs of the people who live at St Michaels. We also looked at what else we already know about the home and compare it with what the proprioter had said the information provided on the (AQAA) documentation we received back. During the site visit four relatives, one professional, three residents and four staff were spoken with during this process. There was also a tour of the premises. What the service does well: What has improved since the last inspection? What they could do better: Just recently the home has not had a registered manager in post. It was apparent throughout the inspection process that there is a lack of a leadership presence on a day-to-day basis. Many inspection records and documentation needed to evidence good and safe practices were not available. St Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 6 Additionally issues raised on the site inspection through surveys and other information collated about the home were unable to be discussed. These issues are important for the safety and protection of residents and management systems need to monitor that practices and procedures are being carried out appropriately. These issues are reflected in many of the areas throughout this document, as is the failure to meet some aspects of the Regulations and Care Standards. 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 Michael`s Care Home for the Elderly DS0000069721.V348088.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 Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an appropriate Service User Guide and Statement of Purpose, which are provided to all prospective residents. EVIDENCE: Prior to admission a statement of purpose and service users guide is given to any potential resident and their family. St Michaels’ Rest Home does not provide intermediate care. St Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 9 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. Care plans do indicate that health care of all residents is fully met. There is no consistency in the recording of medication and systems in place are generally poor. No documentation either from surveys or documentation seen on site suggested that issues raised concerning dignity, respect and consultation has been addressed. EVIDENCE: All resident’s individual care plans were inspected. Information on the whole is to a good standard and demonstrates that although health care is met, there was very little consultation with residents, relatives or their representatives documented within records. All care plans give a comprehensive breakdown of each resident needs including associated risks, however in some care plans and risk assessments they did not clearly evidence that all parties, such as a multidisciplinary team, the residents or representative had agreed the action that may restrict or infringe on an individual’s rights. This type of risk assessment needs to be developed further so that it clearly records that consultation with all parties St Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 10 involved had gone ahead and that they had all agreed to the final outcome of action to be taken. Surveys returned by residents and relatives, and those who were spoken with on the day of inspection had a mixed response about being kept well informed and included about the changes made within the home. Issues that were raised included issues such as preference of times of going to bed and of getting up, activities preferred and offered, preferences to showers or baths, night time support for female residents who may need ‘pad’ changing or dressing/undressing during the night or early mornings when only a male carer is provided to cover the waking night shift. Staff discussion did evidence to some extent that some consultation had gone ahead with individuals, however little or no evidence could be found of this being put into place through any records in individual folders or minutes of residents meetings. Further progress is needed to include and record individuals wishes, views and aspirations. Care plans need further development to be written from that individual’s point of view. If a resident is not able to do this then a representative or advocate can support with this process. This will evidence that consultation, dignity, privacy, respect is in place and if there are any objections by residents or their representatives then how those issues raised will be resolved. The medication cupboard was observed to be locked, however the keys were held within the office and not held by a member of staff. Some stocks of current medication and returns were stored securely; however a large stock of medication returns are kept in an unlocked filing cabinet within the office. Medication had omissions on the MAR sheets. Medication was not booked in or returned routinely as expected. Both monitored dosage systems and single boxes of medication are in use. MAR sheets are photocopies and not original. MAR sheets were kept loose within a folder and may include two separate sheets for one person, which if kept loose is confusing, and no sheets had photographs of the residents on them. This would be particularly confusing for a new member of staff or if agency staff were used in an emergency situation. Additionally there were no guidelines attached to MAR sheets for staff to know information such as, what medication is used for or what the side effects may be. Again no guidelines in place such as, what to do in an emergency or if medication is missed. Samples of staff signatures were not in place. There were no ‘Royal Pharmaceutical Society Guidelines’ or British National Formulary in place for staff to refer to. Staff training records were not available to show that all staff responsible for administering medication had recently received comprehensive medication training, although staff did confirm this was in place. The proprietor should refer to the Skills for Care Knowledge sets for guidance on the minimum content of medication training. St Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. Activity plans are not in place for each individual. The home is providing variety of regular nutritious meals are being provided. EVIDENCE: Within the AQAA returned by the proprietor it stated that a recent residents meeting had taken place where discussion had gone ahead regarding menus and choices of food. Relatives confirmed that they had been invited to the last resident meeting. Some residents and relatives felt that the quality of food was plentiful and good and others felt that not enough food or drinks were available and not enough consultation regarding individuals preferences had been sought. Observation on the day of inspection evidenced that no cold drinks were readily seen to be available in the lounge or were being regularly offered to residents other than at the set meal times. Unfortunately there were no residents meeting minutes available on the day of inspection to evidence this. It is recommended that minutes be typed up and displayed in the home promptly after each meeting, to remind residents and relatives of the discussion, of any action agreed and be available for inspection purposes. St Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 12 Menus submitted as part of this inspection showed two choices for each main meal. Currently opportunities to go out of the home are not frequent and during the inspection most residents were observed to spend most of the day in the main lounge area. Observation showed that over a four-hour period that no activities with individuals were carried out. Two residents, who did carry out an activity, did so because of a relative who had come in to visit and maybe part of their usual routine. The proprietor within the AQAA had stated that activities and opportunities for residents to occupy their time was an area that he wants to develop and needs addressing. The home needs to develop a ‘personal activities plan’ for every resident to evidence what activities are actually planned. If these are refused by individuals, it can still be evidenced that they are offered – this is especially important for those individuals who stay in their private rooms for one reason or another or who have dementia issues. Employing an activity co-ordinator maybe a solution to consider, as staff on shift have little time to fit in any ‘quality’ 1-1-activity time for residents on a day to day basis due to the nature of needs of the client group. No activities book was available on the day of inspection and care plans did not contain much information to support staff to occupy resident’s time or to receive 1-1 stimulation. No staff training certificates for food hygiene were available for inspection. St Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 13 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): 19 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Complaints are not always dealt with appropriately. Training records for staff on Safeguarding were poor. EVIDENCE: Prior to the site inspection no concerns or complaints had been received from the home since being registered in April 2007. It may be the case that complaints or concerns had not been directly raised with the proprietor or any member of staff, however CSCI had received three separate concerns from individuals prior to the site inspection. The first concern raised said that a response from the proprietor to their complaint suggested that he felt it needed no further action, when the complainant felt it did. The second concern received felt that the proprietor and staff were not approachable enough to raise concerns or be able to make an official complaint. The third concern raised felt there was no ‘complaints’ procedure that the proprietor or staff follow. They had wanted a response to a number of issues raised and felt that they had not been acknowledged or that they had a proper response from the home. The proprietor should review the current way in how individuals can make complaints and ensure that all concerns are taken seriously, looked into and that records are kept of these events and are available for inspection purposes. St Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 14 Some of the staff spoken with regarding safeguarding of adults evidenced to me that they had had training and knew the correct response and procedures to follow. No staff training certificates for safeguarding were available for inspection. St Michael`s Care Home for the Elderly DS0000069721.V348088.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The outside environment is pleasant, attractive and provides appropriate and practical usage for the residents. The home environment provides a clean, comfortable and safe environment in which to live in. EVIDENCE: Overall the home presents no health and safety issues and the home was clean, odour free and practical for the use of residents of St Michaels. All personal rooms were viewed and were personalised, showing that residents could bring their own possessions into the home with them. Essential protective clothing such as rubber gloves and aprons for staff were running low on the day of inspection. Staff informed me that further supplies were kept off the premises and they did not have direct access to them. This equipment needs to be readily available as recommended by health and safety guidelines. St Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 16 The home has two different call systems operating within the home. One of the call systems operates from the office and alerts staff to residents who maybe using the toilet facilities. However the home needs take action to address issues relating to autonomy and choice regarding toileting routines in the home as observation showed that at lunchtime a resident who was calling the bell could not be heard for some time due to staff supporting other residents within the dining room and kitchen. This is because the call system cannot be heard clearly from other areas unless you are based within the office at that time. The home needs to ensure all service users have effective equipment assessments in place to ensure they have access to the correct equipment No staff training certificates for universal infection control, manual handling or Health and Safety were available for inspection. St Michael`s Care Home for the Elderly DS0000069721.V348088.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff although good at their roles lacked direction and day-to-day supervision from a leadership The home was very poor at providing necessary records. EVIDENCE: Staff observed and spoken to showed an understanding of their role, and showed patience and care in their interaction with residents. Current staffing at St Michaels consists of two staff throughout the day, and one waking night and one asleep. A sample of the most recent rota was viewed and showed that this level of staffing was consistently being maintained for that week, however the rota was inaccurate on the day of inspection as one member of staff down for afternoon duty was not on duty and another member of staff not on the rota did come in for the afternoon duty. There was no evidence to suggest that the home is using the Skills for Care ‘Common Induction Standards’ as a new member of staff who was spoken with evidenced that they were not aware of this process and had stated that induction consisted of shadowing the more experienced staff and no availability of documentation around this was available to evidence otherwise. St Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 18 There were no records available to show what staff had completed NVQ or that staff are currently put forward to doing this training. No records were available to check staff recruitment procedures. St Michael`s Care Home for the Elderly DS0000069721.V348088.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32,33, 34,35,36,37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Management systems in general are poor. EVIDENCE: In general records, paperwork and essential documentation needs to be reorganised into a clear concise format. During the inspection it was hard to evidence ongoing work due to the either lack of documents or records and general disorganisation of documentation presented. Prior to the site inspection, no Regulation 26 or 37 notices had been forwarded from the home to the CSCI office since being registered in April 2007. Numerous essential records and documentation needed for the inspection were not available, such as the home quality assurance policy/surveys, documentation for money looked after on behalf of residents, Health and Safety policy, documentation for Records of Fire drills and safe working St Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 20 certificates. No members of staff on duty had access to this vital documentation and could not establish where these pieces of documentation are held within the premises. Clearly the lack of a registered manager and staff not having access to essential documentation has resulted in a failure to meet some aspects of the Care Standards. According to the rota and talking to staff, residents and relatives, the proprietor is undertaking regular waking night time shifts and therefore would not be available to lead daytime shifts. Overall the management presence on a day-to-day basis is a priority and needs to be addressed as a matter of urgency. St Michael`s Care Home for the Elderly DS0000069721.V348088.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 3 X X 2 X X X 2 STAFFING Standard No Score 27 2 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 1 1 1 1 1 St Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation Regulation 15 (2)(c) (d) Requirement The home must develop care plans, ensuring that these contain all actions required by staff to meet each persons need. Where possible residents and their supporters should be involved in the development of care plans, and this should be evidenced. The proprietor must ensure Medication all medications are appropriately booked in and accounted for. That MAR sheets are not photocopies and records are held securely. Medication practices must be monitored to ensure that they adequately protect residents. To ensure the protection of residents, all staff must complete appropriate training in safe guarding awareness and the home’s procedures for responding to suspicion of abuse. That this documentation is in place and available for inspection. DS0000069721.V348088.R01.S.doc Timescale for action 31/01/08 2 OP9 Regulation 13 (2) 30/12/07 3 OP18 13(6) 31/01/08 St Michael`s Care Home for the Elderly Version 5.2 Page 23 4 OP26 13(3) To ensure the health and safety of residents, the home must have suitable arrangements and facilities to prevent the spread of infection in the home. That health and safety equipment for staff is accessible and is available for inspection. The proprietor must ensure Staff rota is up-to-date and accurate reflection of staff cover and staff on duty. That this documentation is in place and available for inspection. To ensure the protection of residents, robust recruitment procedures must be followed and all required checks must be carried out on prospective staff prior to them starting work. Documentation demonstrating this must be in place and available for inspection. To ensure that staff have the knowledge and skills to safely meet residents’ needs, they must receive regular relevant training. The home therefore must implement a clear training and development programme for all staff, and documentation demonstrating this must be in place and available for inspection. The registered person must ensure that the home meets the regulatory requirements, for the management of the home. The Registered Person must take action to register a DS0000069721.V348088.R01.S.doc 31/01/08 5 OP27 Schedule 4 (7) 30/12/07 6 OP29 Schedule 2 (2)(1)(2)(3) (4)(5)(6)(7) (a)(b) Schedule 4 (a)(b)(c )(d)(e)(f) 30/12/07 7 OP30 Regulation 18 (1)(c)(i)(ii) 30/12/07 8 OP31 Regulation 8 (a)(b)(i)(iii) 31/01/08 St Michael`s Care Home for the Elderly Version 5.2 Page 24 manager with the CSCI as soon as possible. 9 OP33 Regulation 24 (1)(a)(b) (2)(3) To ensure that the home is run 31/03/08 in the best interests of residents, the home should establish and maintain a system for evaluating the quality of services provided at the care home. This must include systems for obtaining feedback from residents and their representatives about the quality of care in the home, but should also include other quality monitoring processes, including an annual development plan and internal auditing practices. That this documentation is in place and available for inspection. The proprietor must ensure Supervision, staff meetings, staff appraisals and staff induction is in place and that documentation demonstrating this is available for inspection. That all records and essential documentation is in place and available for inspection. The proprietor must ensure that Regulation 26 visits take place and the resulting documentation is in place and available for inspection. The proprietor must ensure that the reporting of notifiable incidents takes place and that relevant documentation is sent to the Commission. 30/12/07 10 OP36 Regulation 18 (2) 11 OP37 Regulation 17(1)(3)(b) Regulation 26 (1)(3)(1)(2) (4)(a)(b) Regulation 37(1)(2) 30/12/07 12 OP38 30/12/07 13 OP38 30/12/07 St Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 2 3 Refer to Standard OP9 OP12 Good Practice Recommendations It is recommended that a photo of residents be provided with their Medication Administration Record. The proprietor should ensure to develop opportunities for activities, consulting with residents over this. Documentation demonstrating this should be in place and available for inspection. It is recommended that the home continue to review menus and meal choices, to ensure a sufficient variety of meals, that meet residents’ choices and preferences are available The home should continue to promote an ethos that encourages people to express any complaints and concerns, and responds to these positively. Documentation demonstrating this should be in place and available for inspection. The proprietor should ensure Call system in toilets meet the needs of the residents by ensuring response times are efficient and that call systems can be heard fro all communal areas. The proprietor should ensure that all safe working documentation relating to certificates should be in place and available for inspection. 4 OP15 5 OP16 6 OP22 7 OP38 St Michael`s Care Home for the Elderly DS0000069721.V348088.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Michael`s Care Home for the Elderly DS0000069721.V348088.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. 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