Inspection on 19/02/07 for St Michaels Nursing Home

This inspection was carried out on 19th February 2007.

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.

Other inspections for this house

St Michaels Nursing Home 07/10/08

St Michaels Nursing Home 10/04/08

St Michaels Nursing Home 10/10/07

St Michaels Nursing Home 31/05/07

St Michaels Nursing Home 11/05/06

St Michaels Nursing Home 28/11/05

St Michaels Nursing Home 18/05/05

St Michaels Nursing Home 08/02/05

St Michaels Nursing Home 05/05/04

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

CARE HOMES FOR OLDER PEOPLE St Michaels Nursing Home Elm Grove Westgate-on-Sea Kent CT8 8LH Lead Inspector Sandra Crosby & Christine Grafton Key Unannounced Inspection 19th February 2007 09:45 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 Michaels Nursing Home DS0000050429.V326912.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 Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 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 Julie Elizabeth Watson Care Home 45 Category(ies) of Dementia - over 65 years of age (45) registration, with number of places St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th May 2006 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. 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, care staff and ancillary staff. There are waking night staff employed. There is a shaft lift to access all floors and a call bell system. It was seen on display at the home that the current range of fees are £386.00 - £580.00, per week. St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The second key inspection visit was unannounced and carried out by two Inspectors on Monday 19 February 2007 between 09.45 and 15.00, and on Thursday 22 February 2007 between 09.45 and 12.45. During the inspection the Inspectors spoke mainly with the Registered Manager, staff on duty, several Service Users and observed practice during the accompanied tour of the home. Various records were examined. The focus of this second key inspection visit was to inspect the home in relation to the Key Standards and check on compliance with the requirements and recommendations made at the first key inspection visit dated 11 May 2006. Feedback from the inspection was provided at the end of the second day of the inspection visit when discussion took place between the Inspectors and the Registered Manager. The Pre-inspection Questionnaire documentation was not requested for this inspection. Observational information and discussion with the Registered Manager, service Users and staff, together with records examined at the time of the inspection, has been used when compiling this report. Since the last key inspection visit dated 11 May 2006 the then Acting Manager has become the Registered Manager. The Inspectors appreciated the helpful attitude and approach to the inspection adopted by the Registered Manager. What the service does well: What has improved since the last inspection? The Manager has become the Registered Manager of the home and is currently undertaking a formal management qualification. The Clinical room has been refurbished, however the temperature in this room was considered to be too high at the time of the visit, for some of the medications stored. The range of activities continues to improve. St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 6 A new industrial washing machine has been fitted. Staff training is ongoing. The kitchen has been refurbished. 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. Service Contracts/Terms and Conditions of Residence to be amended. The Registered Manager to ensure that Service Users are not admitted to the home outside of the homes registered category of Dementia DE(E). Further improvement required in relation to the recording of the Service User plan documentation. Health care needs to be monitored and appropriate action to inform relevant professionals to be taken as necessary. Medication practices to be further improved. The Commission is to be informed in writing of incidents in relation to Regulation 37 Notices. Infection control procedures must be adhered to – provision of liquid soap as appropriate – use of correct category clinical waste bags. 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 appropriate adjustable bed. Staff need to complete further training, especially the mandatory courses and dementia training. Staff to undertake NVQ training as required. Staff need to undertake appropriate induction and foundation training in relation to Skills for Care documentation. Regular supervision of staff needs to be undertaken with written records kept. St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 7 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 Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 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.V326912.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3,4 and 6 were inspected 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, however care needs to be taken to ensure that the home is appropriate to meet Service User needs. Service Users are provided with a written contract/terms and conditions of residency, however the legality of the documented needs to be checked. EVIDENCE: The Statement of Purpose and Service User Guide for the home have been updated and were further discussed. The Registered Manager agreed to make small amendments to both documents and for the documents to be dated in order that these are reviewed in accordance with Regulation. It was evidenced that pre-admission assessments are conducted prior to admission, however it was found that a Service User recently admitted to the home was outside the category that the home is registered for. Action is to be St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 10 taken by the Registered Provider and Registered Manager to address this issue. The contracts/terms and conditions of residence were seen, and it was found that on one form of contract although the home is registered as St Michaels Nursing Home, the documentation stated St Michaels Care Home, and in relation to the Registered Provider the name of the company was different from the name of the Company that is on the registration certificate. The Inspectors were told following a telephone call that action is being taken to address this issue. 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.V326912.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 were inspected 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. Service Users health needs are not always met, although Service Users have full access to all professional health care services as required. Service Users are mainly protected by the home’s policies and procedures for dealing with medicines but some minor errors were highlighted. Dignity and privacy is now maintained in shared bedrooms. EVIDENCE: Five Service User plans were seen and improvements were noted. The Service User Plans contained all components required by regulation, however one Service User plan failed to identify that action had been taken in relation to an ongoing medical condition. This issue was discussed with the Deputy Manager and he confirmed on the second day of the inspection visit that action had now been taken by the home to address this health care need. Discussion took place with the Deputy Manager in relation to the wound plans and records and he agreed to ensure that these are maintained appropriately. St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 12 Medication records were seen and on the whole were appropriately signed. Issues raised were in relation to the practice of re-sheathing needles – being unable to audit trail a medication – list of staff signatures out of date – some records did not have a photo of the Service User. The Deputy Manager agreed to address these issues. The clinical room was tidy, however the temperature was approximately 26c, and may be above the temperature that some medications can be stored at. There was no indication on the copies of the staff training matrix supplied as to the medication training undertaken by the nursing staff, however following the key inspection visit in May 2006 the then Acting Manager confirmed that staff had undertaken medication training in July 2005. It was again found that at least one of the bedroom doors had no door handle mechanism showing that the door could just be pushed open. Action needs to be taken to address this issue in relation to dignity and privacy. St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 were inspected Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. As the home is registered for Dementia Category, it is difficult to judge if the lifestyle the Service Users experience in the home matches their expectations and preferences. The home endeavours to provide suitable services to meet Service Users needs and a range of activities are provided. Service Users are able to maintain contact with family and friends. EVIDENCE: The Inspectors were shown a recent newsletter that the Registered Manager had produced for the home, and within this were details about planned activities. The newsletter was well presented and interesting with pictures as well as written text. The home currently has an activities co-ordinator, and individual written records were seen. The activities co-ordinator was observed spending one-toone time with Service Users. The previous 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. Service Users told the Inspectors about a recent trip out to see a Pantomime and expressed how much they had enjoyed the outing. St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 14 Service Users maintain contact with family and friends, and one Service User talked about their family visiting, and the fact that she enjoyed entertaining her family in her bedroom. The kitchen has recently been refurbished, and discussion with the cook confirmed that the area has been well planned. The food storage areas were seen, and contained suitable and sufficient supplies, and the cook said that fresh vegetables are always used. It was seen that there is always a choice of meals available and Service Users confirmed that they enjoyed the food provided at the home. St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints record was seen and indicated that complaints are recorded together with action taken and the outcome, thereby Service Users/relatives and friends can be confident that their complaints are listened to, taken seriously and acted upon. Further staff training in relation to adult protection needs to be undertaken in order to ensure Service Users are protected from abuse. EVIDENCE: The documentation of recorded complaints was seen, and the records showed that action taken was appropriate and recorded. The staff training matrix indicates that ten members of staff have undertaken training in Adult Protection. Further members of staff at the home need to undertake this training, and the Registered Manager said that training is ongoing at the home. St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20,21,22,23,24,25 and 26 were inspected. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service Users do not benefit from living in a home where the routine maintenance, decoration, and renewal of the fabric of the premises are regularly maintained, and refurbishment is required in some areas. The building is not well maintained, does not provide sufficient assisted baths to meet the needs of the Service Users and does not always 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 then Acting Manager explained that the boilers were not to be turned off otherwise the home would not have any hot St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 17 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 that a contractor would be starting work at the home the following week in order to address this serious issue. It was found at this inspection visit that the home was again very hot, and the Registered Manager said that boilers had not been replaced, and that action taken since the last inspection visit was that the one boiler (second boiler not working) that was in use had been serviced. The current situation is unacceptable and an immediate requirement letter has been sent to the home to address this situation. The overall maintenance of the home is limited, for example in one bedroom it was seen that the paint had been touched up, however the colour was not a match for the original and the overall effect was not pleasing. It was again observed during the course of an accompanied tour of the environment that Not all Service Users receiving nursing care had appropriate adjustable beds. Brakes not on – on a number of hospital beds Several taps were seen that were constantly running Odour was noted in several rooms No Category A Clinical Waste Bags – Requirement given at last inspection Inappropriate swing lid bins seen No liquid soap as appropriate Sheets laundered but not ironed Audit of bedding and armchairs needed - requested at last inspection Items seen in Chapel - to be stored appropriately elsewhere 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. Previous requirements have been given. The Company was 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. This was never forthcoming and at this visit it was seen that the upgrade of the kitchen had been completed. St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users needs are met at all times by the numbers and skill range of the staff. Service Users are protected by the home’s thorough recruitment procedures, and staff training is ongoing. EVIDENCE: The staff rota was seen, and currently with 27 Service Users it is indicated that there are sufficient staff on duty to meet the needs of the current group of Service Users. There is however no evidence to show that an RMN has been appointed, and this issue was one that the Registered Manager said was being addressed in May 2006. 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 current staff training matrix shows three of the nursing team and ten care staff have not completed training in Dementia Care, and it is also indicated that none of the ancillary staff have completed any form of training in Dementia care Staff files were seen and on the whole a thorough recruitment system is in place. It was discussed that the staff contracts should state the appropriate registered company’s name and the Registered Manager agreed to take action in relation to this issue. St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 19 The content of the induction training needs to be improved, and discussion took place with the Registered Manager in relation to the Skills for Care Induction and Foundation training, and she said she would address this issue. St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32,33,35,36,37 and 38 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service, but determined mainly due to the manager’s performance, without which the overall outcome for this group of standards would have been judged as poor. The leadership provided by the Registered Manager is having a positive effect on the way the home is being run for the benefit of the Service Users however, Service Users and staff cannot always be confident that their health, safety and welfare are promoted and protected. EVIDENCE: Whilst the Registered Manager has a good understanding of what needs to improve in the home, the support and cooperation of the registered providers is essential to bring about and sustain the improvements needed to protect Service Users best interests. The Registered Manager indicated that she has been doing her best to address the outstanding requirements, but cannot St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 21 always achieve the desired results. This is due to delays, or in some cases, such as the problem with the boiler, lack of action, on the part of the senior management structure of the owning company registered in respect of this home. The personal allowance records were seen and the system of documentation shows a clear audit trial of monies handled on behalf of Service Users. The Registered Manager stated that staff are receiving supervision, however following discussion it is again indicated that this needs to be on a more regular basis with written records kept in order to comply with the requirements of this standard. Training has been ongoing at the home according to the staff-training matrix, with for example Moving and Handling and Fire Training being undertaken in 2006. There are however still a number of staff that need to undertake mandatory training as required for example Health & Safety and Infection Control. There is a quality assurance system in place at the home. St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 2 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 2 2 2 2 1 1 1 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 3 1 St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Schedule 1 and 5 Timescale for action Small amendments to be made 31/03/07 to the Statement of Purpose and Service User Guide in order to fully comply with the Regulations Previous requirements have been made under this standard 31/08/06 2. OP4 14(1) (d) The registered person shall not 31/03/07 provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so (d) the registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service users’ needs in respect of his health and welfare Service User admitted to home outside of the homes registered category of Dementia DE(E) 3. OP7 15 A service user plan of care 28/02/07 generated from a comprehensive assessment (see Standard 3) is DS0000050429.V326912.R01.S.doc Version 5.2 Page 24 Requirement St Michaels Nursing Home drawn up with each service user and provides the basis for the care to be delivered Accurately detail individual assessed needs and ensure that these needs are met Wound Care Plans and documentation to be improved Previous requirements have been made under this standard 31/07/04 31/07/05 31/03/06 11/05/06 4. OP8 12 The registered person promotes 28/02/07 and maintains service users’ health and ensures access to health care services to meet assessed needs Monitor health care needs and take appropriate action as necessary – high blood sugar levels 5. OP9 12,13,14, 16 The Registered Person shall 28/02/07 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medications Full audit trail of medications needed Stop the practice of re-sheathing needles List of staff signatures out of date Some records did not have a photo of the Service User – Temperature in clinical room needs to be reduced Previous requirements have been made under this standard 31/01/06 11/05/06 St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 25 6. OP10 13(4) The registered person shall make 31/03/07 suitable arrangements to ensure that the care home is conducted (a) in a manner which respects privacy and dignity of service users Provide suitable mechanisms to comply regulation door with 7. OP18 18 The registered person ensures 30/06/07 that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies All staff to have undertaken training in relation to abuse/adult protection 8. OP19 37 The registered person shall give 31/03/07 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 Prior notification of the re-fitting of the kitchen especially as the main kitchen was out of action for a period of time Previous requirements have been made under this standard 30/06/06 St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 26 9. OP21 23 Toilet, washing and bathing 31/03/07 facilities are provided to meet the needs of service users To provide the CSCI with an action plan with timescales regarding the home bathrooms/service user ratio Previous requirements have been made under this standard 31/0/04 31/07/05 31/03/06 30/06/06 10. OP22 13 The home must identify and 28/02/07 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 Correct storage of seen in the Chapel the items Previous requirements have been made under this standard 28/11/05 31/07/06 11. OP24 16 The home provides private 31/03/07 accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user Appropriate adjustable beds must be provided for those service users receiving nursing care Previous requirements have been made under this standard 28/11/05 31/07/06 12. OP24 23 The home provides private 31/03/07 accommodation for each service DS0000050429.V326912.R01.S.doc Version 5.2 Page 27 St Michaels Nursing Home user which equipped to privacy, and needs of the is furnished and assure comfort and meets the assessed service user To provide the CSCI with a written action plan that includes timescales for the ongoing refurbishment both internally and externally of the home Previous requirements have been made under this standard 31/08/04 31/05/05 31/07/05 31/03/06 30/06/06 13. OP25 23 The heating, lighting, water 31/03/07 supply and ventilation of service users’ accommodation meet the relevant environmental health and safety requirements and the needs of individual service users Action to be taken in relation to the boilers at the home functioning appropriately Previous requirements have been made under this standard 31/03/06 11/05/06 14. OP26 12,13,16, 23 The premises are kept clean, 28/02/07 hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance Infection control procedures must be adhered to by all staff Foot operated pedal bins must be provided as appropriate Correct category clinical waste bags must be used for the disposal of clinical waste St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 28 Previous requirements have been made under this standard 31/03/06 11/05/06 15. OP28 18 A minimum ratio of 50 trained 30/09/07 members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses Previous requirements have been made under this standard 28/11/05 30/09/06 16. OP30 12,13,18 The registered person ensures 30/09/07 that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users All staff to complete 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 Staff to undertake Skills for Care Induction and Foundation Training Previous requirements have been made under this standard 28/11/05 31/07/06 St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 29 17. OP36 18 The registered person ensures 31/03/07 that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice All staff must receive formal supervision with written records kept Previous requirements have been made under this standard 31/12/04 31/07/05 31/07/06 18. OP38 13(3)(4) The registered manager ensures 31/03/07 so far as is reasonably practicable the health, safety and welfare of service users and staff Staff to undertake mandatory training e.g. Health & Safety and Infection control Previous requirements have been made under this standard 28/11/05 30/06/06 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. Refer to Standard OP2 Good Practice Recommendations Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately) Contracts/Terms and Conditions of Residence should reflect the registered name of the home together with the name of the Company that is shown on the Registration St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 30 Certificate 2. OP29 The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users Staff contracts to company’s name state the appropriate registered St Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Michaels Nursing Home DS0000050429.V326912.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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