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Inspection on 11/05/06 for St Michaels Nursing Home

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

This inspection was carried out on 11th May 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 benefits from a caring team of staff, and an Acting Manager who demonstrates good rapport with Service User and is supportive to the staff team. Refurbished bedrooms are pleasantly decorated and furnished, with service users encouraged to personalize their rooms by bringing in their own possessions.

What has improved since the last inspection?

The Statement of Purpose and Service User Guide have been updated. Clinical room has been refurbished. The range of activities is improving; however further action is required in this area. A new industrial washing machine was in the process of being fitted. The personal allowance records system of documentation has improved, and the Acting Manager has worked hard to ensure that Service Users receive their allowances.

What the care home could do better:

Small amendments to be made to the Statement of Purpose and Service User Guide in order for these documents to fully comply with Regulation 4 Schedule 1 and Regulation 5. Further improvement required in relation to the recording of the Service User plan documentation. Nursing needs must be clearly identified in the care plan and recorded as provided in daily reports. The recording of medication records to be improved. The record of the food provided at the home to be comprehensive and include all food provided at all mealtimes. The Commission is to be informed in writing of incidents in relation to Regulation 37. Infection control procedures must be adhered to.The registered provider needs to produce and implement an action plan for completing the outstanding refurbishment of the building. The hot water boilers need to be fully operational. Service users receiving nursing care should be provided with an adjustable bed. The employment of adaptation student needs reviewing to reduce the frequent changes in staff and the impact of the high level of overseas staff employed with the communication problems service users encounter. The recruitment procedures of prospective staff needs to be more thorough ensuring all of the checks are conducted prior to them starting work. All staff need to complete more training, especially the mandatory courses and dementia training. Staff to undertake NVQ training as required. Staffing levels need to be reviewed. Regular supervision of staff needs to be undertaken.

CARE HOMES FOR OLDER PEOPLE St Michaels Nursing Home Elm Grove Westgate-on-Sea Kent CT8 8LH Lead Inspector Sandra Crosby Unannounced Inspection 11th May 2006 11:30 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 Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 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 Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Michaels Nursing Home Address Elm Grove Westgate-on-Sea Kent CT8 8LH 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) 01843 835709 01843 832905 Charing Healthcare Care Home 45 Category(ies) of Dementia - over 65 years of age (45) registration, with number of places St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To change category to DE(E) over a phased period with no more than two (2) admissions per week. To admit one (1) younger adult, with a mental illness, whose date of birth is 10/04/1943. 28th November 2005 Date of last inspection Brief Description of the Service: St Michaels Nursing Home is a large attractive three storey detached home with small garden areas. It is situated close to the sea and is a short journey to the local amenities. The home is registered for the provision of nursing care for people with Dementia, and is in the process of changing from providing nursing care for the older person. Although the Home is registered for 45 service users, currently the Home does not use all of these places. The Home employs a Manager and a team of Registered Nurses and care staff. There are waking night staff employed. There is a shaft lift to access all floors and a call bell system. The scale of charges at the home are £497.35 - £580.00, per week. St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the Inspectors first visit to the home. The key inspection visit was unannounced and carried out over two visits the first on Thursday 11 May 2006 between 11.30 and 15.15, and the second on 12 May 2006 between 09.30 and 13.00. A telephone conversation was held with the Acting Manager for clarification on some issues. A further short visit was made to the home on the 18 May 2006 to provide feedback summary sheets to the Acting Manager. On the first day of the inspection the Inspector spoke mainly with the Acting Manager, staff on duty and briefly with service users during the accompanied tour of the majority of the premises. Various records were seen. On the second day the Inspector mainly spoke with the Acting Manager and Nursing Home Supervisor, and serious issues of concern were discussed with the Group Manager. Various records were seen and an accompanied tour of the premises. The key standards were inspected at this inspection visit. The atmosphere of the home was welcoming, calm and relaxed, and the home was clean and orderly at the time of the inspection visit. As this inspection was carried out at short notice, only the Pre-inspection Questionnaire documentation was sent to the home prior to the visit. Service User Comment Cards or Relatives Comments Cards were sent out after the inspection visit. As at 14th June 2006 Five Relatives/Visitors Comment Cards and Five Care Homes Surveys have been received and these on the whole commented positively on the services and care provided at the home. The Pre-inspection Questionnaire completed by the home together with observational information and discussion with the Acting Manager, Area Manager, Manager from another home together with Service Users and staff at the time of the inspection, has been used when compiling this report. It was found that the management and staff at the home were working hard towards setting up the necessary systems in order to comply with the requirements of the regulations. The information in this inspection report indicates that the home is striving to comply in full with all aspects of the Standards. It was observed that the Acting Manager has a good rapport with Service Users, and is supportive towards the staff group. St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Small amendments to be made to the Statement of Purpose and Service User Guide in order for these documents to fully comply with Regulation 4 Schedule 1 and Regulation 5. Further improvement required in relation to the recording of the Service User plan documentation. Nursing needs must be clearly identified in the care plan and recorded as provided in daily reports. The recording of medication records to be improved. The record of the food provided at the home to be comprehensive and include all food provided at all mealtimes. The Commission is to be informed in writing of incidents in relation to Regulation 37. Infection control procedures must be adhered to. St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 7 The registered provider needs to produce and implement an action plan for completing the outstanding refurbishment of the building. The hot water boilers need to be fully operational. Service users receiving nursing care should be provided with an adjustable bed. The employment of adaptation student needs reviewing to reduce the frequent changes in staff and the impact of the high level of overseas staff employed with the communication problems service users encounter. The recruitment procedures of prospective staff needs to be more thorough ensuring all of the checks are conducted prior to them starting work. All staff need to complete more training, especially the mandatory courses and dementia training. Staff to undertake NVQ training as required. Staffing levels need to be reviewed. Regular supervision of staff needs to be undertaken. 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 Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The statement of purpose requires further amendment to enable prospective service users to make an informed decision. Prospective service users are assessed prior to admission. EVIDENCE: The Statement of Purpose and Service User Guide for the home have been updated and were discussed. The Acting Manager agreed to make small amendments to both documents for example a copy of the homes contract/terms and conditions is attached to the Service User Guide. It was reported at the last inspection visit that Pre–admission assessments are conducted and it was shown at that time that the Acting Manager had been confident in the findings of these to decline an admission to the home recently for a service users they believed would be an inappropriate admission. St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 10 It has been previously stated that Standard 6 the provision of intermediate care is not applicable in relation to this home. St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual care plans and daily records have improved but still fail to identify all aspects of service users care needs. Dignity and privacy is now maintained in shared bedrooms. Medication practices have improved, however further improvement is needed. EVIDENCE: Two Service User plans were seen, and contained all components required by regulation, however the care plans still do not contain all of the required information to instruct care staff on how to provide the individual care. One Service User plan failed to identify medical conditions that were evidenced in the assessment information and would need to be part of the plan of care and the second Service User plan failed to record necessary information in relation to health care needs and catheter care. The first issue was discussed with the Acting Manager and the second issue was discussed with the Acting Manager, the Nursing Home Supervisor and a member of the nursing staff. It is indicated that staff are working hard to ensure that the standard of Service User plan documentation is improved. St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 12 Two position-changing charts were seen in a double bedroom. They each had one entry at 9.00am, and the persons seen were still in the same position at 14.00. The recording of these records was discussed with the Acting Manager. The health/care needs, of a person seen in wheelchair was discussed with the Acting Manager, as the Service User was insufficiently supported and leaning to one side. The Acting Manager took immediate action to address this issue. Medication records were seen and on the whole were appropriately signed, although a number of gaps in recording were seen and discussed with the Acting Manager. Evidence was seen from a GP that it was acceptable for named Service Users to have their tablets crushed, however there was no supporting evidence seen in the Service User plans as to why this action was taken. This issue was discussed with the Acting Manager. The refurbishment of the Clinical Room has been completed, and provides an improved facility at the home. The storage of medications was not examined at this visit. Following the Key Inspection Visit the Acting Manager confirmed that staff had undertaken medication training in July 2005. From observations when undertaking the accompanied tour of the home it was seen that Service Users are treated with respect, in relation to privacy it was observed that two of the bedrooms doors seen had no door handle mechanism showing that the door could just be pushed open. The Acting Manager agreed to address this issue. St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected 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 adequate. This judgement has been made using available evidence including a visit to this service. There are now some activities provided within the home. Alternative choices of meals have improved however, the food records do not give a clear indication of the food provided at the home. EVIDENCE: The Inspector was shown a newsletter that the Acting Manager had produced for the home, and within this were details about some planned activities. She said that there was going to be a monthly newsletter and from the information seen the newsletter was well-presented and interesting with pictures as well as written text. The home currently has an activities co-ordinator, however written records require improvement in order to assess how the person uses their time. The Inspector was told that the activities co-ordinator spends one-to one time with Service Users. The Pre-inspection questionnaire states that recreational activities in the home include concerts, Holy Communion, church services, pastoral visits, reminiscence, sing-a-longs-raffles, competitions and parties. The Acting Manager said that she is still actively working towards promoting further recreational activities in the home. St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 14 The record of the food provided at the home need to be dated and provide more detail for example there were on a number of occasions no evidence of a choice of dessert, and not a complete record of the teatime food provided. Following discussion with the Acting Manager and Nursing Home Supervisor it was agreed that a full record of the food provided at the home would be maintained. One Service User said that she had enjoyed her Jacket Potato and Chicken that she had had for lunch on the first day of the key inspection visit. St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be 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 adequate. This judgement has been made using available evidence including a visit to this service. Relatives and service users are confident that their views and concerns will be taken seriously. EVIDENCE: The complaints record was seen, and the Pre-inspection questionnaire states that five complaints have been received since the last inspection, and that four of these were substantiated and one was partially substantiated. The records seen showed that action taken was appropriate in most cases and recorded. For one Service User complaint it may have been of use to cross-reference the information to the Service User Plan. In relation to one incident action has been taken by the home. During discussion it was shown that the Commission had not been informed until after a disciplinary hearing had taken place and the Inspector has requested that the home confirms in writing to the Commission that the person concerned has been referred as necessary to POVA and the NMC. The Pre-inspection questionnaire states that two staff members undertaken Adult Protection training in the past twelve months. have St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 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 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 poor. This judgement has been made using available evidence including a visit to this service. The building is not well maintained. The Home does not provide sufficient assisted baths to meet the needs of the service users. The Home does not comply with infection control procedures. EVIDENCE: A requirement was given following the announced inspection dated 28 November 2005, in relation to the renewal of the boilers for the provision of hot water and heating. The Inspector was told that action had been taken to seek estimates from a number of companies, however at the time of this inspection the premises was uncomfortably hot, all the windows were open and the radiators were very hot. The Acting Manager explained that the boilers were not to be turned off otherwise the home would not have any hot water. On the second day of the inspection visit the Inspector spoke with the Group Manager who discussed the action that had been taken to date, and during the course of the morning was able to provide written information that confirmed St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 17 that a contractor would be starting work at the home the following week in order to address this serious issue. The overall maintenance of the home is limited. The planned remaining refurbishment of the home has not been completed although some refurbishment work has been undertaken. One bedroom was reported in the last report as having been locked to protect service users and the public due to it being in an unsafe state. It was observed during the course of an accompanied tour of the environment that not all Service Users receiving nursing care had appropriate adjustable beds. The Acting Manager has since confirmed that there is an ongoing programme to provide the necessary adjustable nursing beds. The bathroom containing the parker bath has been re-decorated and tiled. The registered provider has not responded to the requirement to submit an action plan in relation to the provision of assisted bathrooms, since a bathroom was turned into a store cupboard. It was seen that the hot water tap in the bathroom was constantly running and the Acting Manager agreed to address this issue. A new industrial washing machine was being installed at the time of the inspection visit, and no judgement was made in relation to the laundry area at this time. In relation to the control of infection it was seen that there was not always the required pedal bin in place, that not all soap dispensers contained soap, there were odours in some areas of the home, and incorrect category clinical waste bags were being used. The Acting manager agreed to address these issues and on the second day of the inspection visit showed the Inspector written confirmation that a number of the Category A clinical waste bags had been ordered. During the accompanied tour the Acting Manager was requested to ensure that all lino in use at the home is of the non-slip category, that carpet edges as taped securely as necessary, and that cleaning chemicals seen are not left unattended in any area of the home. It is requested that the Acting Manager audit the bedding and armchairs in the home as some examples seen need replacing. A couple of newly refurbished bedrooms were seen, and only require minor repairs in order for them to be useable. The Inspector was told at the feedback summary visit, that action is being taken by the Company to ensure that the lift remains fully operational. St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 18 The Company is requested to provide written information in relation to the upgrade of the kitchen, including provision of an action plan that sets out the period of time this upgrade is to take place, and the measures taken to ensure continuity of service during this time. St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected 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 this service. The staff complement and frequent changes of staff has a detrimental impact on the care provided and causes the service users distress. Staff have not as yet completed all the training required to fulfil their roles and responsibilities. EVIDENCE: The staff rota was seen, and from evidence seen of high dependency needs the home needs to readjust staffing levels and the Acting Manager said that she is actively working towards adjusting the staff levels in order to meet the needs of the current group of Service Users. At the time of the visit the home had no RMN, however action has been taken to resolve this issue. When the change to the registration to the home was approved for caring for those with dementia-nursing needs, the proposal included a commitment to all staff completing dementia training. The Inspector was told that the majority of staff have undertaken training in relation to dementia. Training records were not evidenced, the pre-inspection questionnaire indicates that training has been ongoing, however all of the staff have not as yet completed all mandatory training courses. The Acting Manager said that the last group of adaptation nurses finish training at the end of May. It has previously been stated that the Service Users expressed how unsettling they find this changeover of staff and that they just St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 20 get used to the staff and then they leave. They also expressed their problems with understanding the overseas staff. It was indicated that this situation would be resolved. Staff files were seen and on the whole a thorough recruitment system is in place, however the Acting Manager needs to ensure that all the required checks and references are undertaken. St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home has changed frequently causing a lack of continuity, however the current Acting Manager indicates commitment to complying with the requirements of the standards and regulations. EVIDENCE: The Acting Manager demonstrated a good rapport with Service Users, and was observed as being supportive to the staff. She is actively working towards complying with the standards and regulations. The personal allowance records were seen and the system of documentation has improved. The Acting Manager has jointly worked with other professionals in order to ensure that Service Users receive their allowances. St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 22 The Acting Manager stated that staff are receiving supervision, however following discussion it is indicated that this needs to be on a more regular basis in order to comply with the requirements of this standard. Staff should undertake all mandatory training as required for example Moving and Handing. The boilers are the home need to be attended to in order that the central heating may be turned off without this affecting the supply of hot water for the premises. Action is being taken in relation to this issue. St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 2 2 2 2 3 1 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 2 2 2 St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 24 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. 2. Standard OP1 OP7 Regulation 4 Schedule 1 12,13,14, 15,16,18 Timescale for action Small amendments to be made 31/08/06 to the Statement of Purpose Required to produce individual 11/05/06 Service User care plans that accurately detail individual assessed needs and ensure that these needs are met. That reviews are conducted monthly or sooner if changes are noted, for changes/ deterioration to be recorded and appropriate action to be taken Previous timescales 31/07/04, 31/07/05, 31/03/06 Nursing needs must be clearly 11/05/06 identified in the care plan and recorded as provided in daily reports Previous timescale 31/03/06 The registered person shall give 11/05/06 notice to the Commission without delay of the occurrence of – any allegation of misconduct by the registered person or any person who works at the care home DS0000050429.V291821.R01.S.doc Version 5.1 Page 25 Requirement 3. OP8 12,13,14, 15,16,18 4. OP18 37(1)(e) St Michaels Nursing Home 5. OP9 12,13,14, 16 The Registered Person shall 11/05/06 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medications Records of medication sent for disposal/destruction must be kept – This was not assessed at this inspection visit (Timescale 31/01/06) An activities programme that 31/08/06 reflects the interests and needs of the service users must be provided Previous timescale 31/03/06 Records of the food provided for 11/05/06 service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory in relation to nutrition and otherwise, and of any special diets prepared for individual service users The registered person shall give 30/06/06 notice in writing to the Commission as soon as it is practicable to do so if any of the following events takes place or is proposed to take place – the premises of the care home are significantly altered or extended, or additional premises are acquired To provide the CSCI with a 30/06/06 written action plan that includes timescales for the ongoing refurbishment both internally and externally of the home Previous timescales 31/08/04, 31/05/05, 31/07/05, 31/03/06 To provide the CSCI with an 30/06/06 action plan with timescales regarding the home bathrooms/service user ratio DS0000050429.V291821.R01.S.doc Version 5.1 Page 26 6. OP12 12,14,15, 16,23 7. OP15 12,13,14, 15,16, 17(2) Sch 4 8. OP19 39 9. OP24 12,13,23, 14,16 10. OP21 23 St Michaels Nursing Home 11. OP25 12,13,16, 23 Previous timescales 31/0/04, 31/07/05, 31/03/06 Action to be taken in relation to 11/05/06 the work being carried out in order that the boilers at the home function appropriately The registered provider must submit an action plan to the CSCI for the renewal of the boilers for the provision of hot water and heating (Previous timescale 31/03/06) The home must identify and 31/07/06 provide sufficient storage for the items needed to meet service users needs (such as feeds, continence aids, movement & handling equipment) and not use communal space/rooms for this purpose The timescale was given at the inspection report dated 28/11/05 and was not assessed at this inspection visit Adjustable beds must be 31/07/06 provided for those service users receiving nursing care The current timescale was given at the inspection visit dated 28/11/06 Infection control procedures 11/05/06 must be adhered to by all staff Foot operated pedal bins must be provided as appropriate Previous timescale 31/03/06 Correct category clinical waste bags must be used for the disposal of clinical waste The registered person must 31/08/06 review the high numbers of adaptation students working within the home and to reduce DS0000050429.V291821.R01.S.doc Version 5.1 Page 27 12. OP22 12,13,23, 14,16 13. OP24 16 14. OP26 12,13,16, 23 15. OP27 18 St Michaels Nursing Home the frequent turn over of staff 16. OP28 18 Previous timescale 31/03/06 50 of the care staff must 30/09/06 achieve NVQ level 2 in care Previous requirement The current timescale was given at the inspection visit dated 28/11/06 To ensure that prospective staff 30/06/06 are recruited ensuring the protection of service users and that staff files are audited to ensure they contain the required forms of documentation Previous timescales 31/08/04, 31/07/05, 31/01/06 All staff must complete the 31/07/06 mandatory training All staff must complete Dementia training - senior staff should attend an in depth/advanced course, junior staff (including ancillary staff) should complete at least a basic introduction to dementia course This requirement has been partly met as most staff have now undertaken training. The current timescale was given at the inspection visit dated 28/11/06 All staff must receive formal 31/07/06 supervision six times a year Previous timescales 31/12/04, 31/07/05 The current timescale was given at the inspection visit dated 28/11/06 Staff to undertake mandatory 30/06/06 training e.g. Moving and DS0000050429.V291821.R01.S.doc Version 5.1 Page 28 17. OP29 7,8, 18,19,sch 2 18. OP30 12,13,18 19. OP36 18,19 20. OP38 13(3)(4) St Michaels Nursing Home Handling The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Michaels Nursing Home DS0000050429.V291821.R01.S.doc Version 5.1 Page 30 - 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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