Inspection on 21/01/08 for St Saviours Care Home

This inspection was carried out on 21st January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE St Saviours Care Home 5 Lidget Lane Retford Nottinghamshire DN22 6QW Lead Inspector Stephen Benson Unannounced Inspection 21st February 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Saviours Care Home DS0000070684.V359923.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 Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Saviours Care Home Address 5 Lidget Lane Retford Nottinghamshire DN22 6QW 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) 01246 471 991 St Saviours Care Homes Ltd Mrs Janet Mary Briddon Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following category: Old age, not falling within any other category - Code OP. The maximum number of service users who can be accommodated is 40. N/A New service 2. Date of last inspection Brief Description of the Service: St Saviours is a care home providing personal care and accommodation for 40 older people. The home provides short and long care and will accept emergency admissions. The home is owned by St Saviours Care Home Limited which is run as a family business. The home is located in a residential area of Retford, close to shops, pubs, the post office and other amenities. The home was opened in August 1995, with the most recent change of ownership in September 2007 and consists of a purpose built building. All of the home’s bedrooms are single, and 15 of the bedrooms have en-suite facilities. Bedrooms are located on 2 floors and there is a passenger lift. The home has 3 enclosed garden areas that are well maintained and easily accessible. There is ample car parking available. The manager said on 21/02/08 that the fees for the service range from £290 £349 per week depending on dependency needs. There are additional charges for hairdressing and chiropody. Further information about the home is available from the provider, the manager or the website: www.fbccarehomes.com St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was our first visit to the home since the change in ownership in September 2008. Prior to the visit an analysis of the home was undertaken from information gathered since then including that from the Annual Quality Assurance Assessment they completed. The visit centred on looking at the key National Minimum Standards for older people. The site visit lasted for 6 hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the provider, the manager, staff on duty and care practices were observed. Some visitors to the home were spoken with during the visit. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. What the service does well: Prospective new residents are assessed to make sure that the home is able to meet their needs. Staff will contact healthcare professionals to see to the healthcare needs of residents and their health is monitored through observation and regular health checks. There are safe practices followed in the management of residents’ medication ensuring they receive the correct medication when required. Staff are trained to respect the privacy and dignity of residents and know good practices for doing this. This ensures that residents’ privacy and dignity are promoted. Residents are able to keep in contact with their families and friends who are welcome to visit the home at any time and can take residents out if they wish. Residents are able to choose how they spend their time and are supported by staff to make choices where they are able so that residents remain in control of their lives as much as they are able. St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 6 There is a varied menu with a choice of main meal and further alternatives are available. The dining rooms were well presented and the food looked appetising. This ensures that residents have a nutritious and balanced diet in pleasant surroundings. The home is well maintained and kept clean and tidy which means residents live in a comfortable environment. New staff can only start work when the required checks have been carried out, including a satisfactory Criminal Records Bureau or Protection of Vulnerable Adults check. Staff training needs have been identified and a training programme is being prepared to meet these. There is a suitably qualified and experienced manager in post who has been registered. What has improved since the last inspection? What they could do better: Assessment documentation should be amended to allow for information concerning residents’ ethnic origin and any significant relationship to be obtained. Care plans must clearly describe how resident needs are to be met and where a need is identified a care plan must be written for this so that staff know how to meet residents’ needs. More frequent and varied activities must be provided so residents have opportunities to spend time doing things they find enjoyable and stimulating. The complaints procedure should be promoted so that the process to make a complaint is know by staff and residents, and a record of all complaints is made. All staff must be familiar with the procedures to follow to safeguard residents if there is any suspicion of abuse. There should be sufficient staff on duty to enable residents’ social and recreational needs to be met. St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 7 A formal system is required that enables residents to express their views on how the home is run. 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 Saviours Care Home DS0000070684.V359923.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 Saviours Care Home DS0000070684.V359923.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): 3 and 6 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. New residents are fully assessed prior to moving into the home to ensure that their needs can be met. The home does not offer an intermediate care service EVIDENCE: A recently admitted resident was one of the people case tracked and there was a Local Authority assessment seen on the care file which had been faxed to the home prior to the person being admitted. There was an admission assessment partly completed and this was being added to through a discussion with a relative who was visiting the home. The relative signed the form to show her agreement. St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 10 The assessment information did not include obtaining details regarding residents’ ethnic origin and only asked whether the person was married or single and did not allow for anyone to refer to any significant relationship they have or had. The relative said that their first impressions of the home had been brilliant and had discussed the care needed with the manager over the telephone. Following on from that discussion the relative had visited the home and had been shown everywhere. The manager said that on most occasions she will go to visit any prospective resident to assess their needs, but had not been able to do so on this occasion due to time constraints. There were two further admissions planned and the manager said these people were already known to the home as they had previously used the service for respite care. There were completed assessments seen on other residents’ care files, although some of these were not fully completed. Staff said that the manager goes to assess any prospective new resident, sometimes with the provider and they receive faxes from social workers about any new resident. The newly admitted resident said, “I am getting the help I need”. The manager said that anyone is welcome to apply for a place providing they fall within the registration category for the home. The manager said that there are male and female residents all whom are of white British origin. There has not been a resident from another culture at the home. There is no arrangement made for the home to provide an intermediate care service. St Saviours Care Home DS0000070684.V359923.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): 7, 8, 9 and 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are not person centred and do not look at all areas of the individual’s life. Residents’ health needs are met by care practices in the home and their privacy and dignity is promoted. EVIDENCE: There were care files for each resident and a sample of three files were looked at. There was a risk assessment form that assessed physical, psychological and environmental risks. There were some risk assessments, for example nutrition, tissue viability and mobility that were not fully completed and there were some seen that indicated a level of risk but there was not care plans prepared to reduce these. St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 12 There were some entries in care plans that had not been kept updated and some instructions were too vague, for example one plan stated that one residents television is to be switched off at a reasonable hour, but does not state what time that is and whether this was with the agreement of the resident concerned. Another entry in a care plan referred to a resident waiting for some new shoes to be made for him, but there was no mention if they had been received. The resident said that they had arrived and were in the office. The manager said that either she of the deputy manager complete the care plans and that this had been a massive task to undertake following the reopening of the home. The manager said she was aware that they had not been fully completed yet, but she expected them to be completed over the next two weeks. Staff said that the manager and deputy manager complete the care plans and they write up the communication sheets and monitoring forms. Staff said they find care plans useful to find out about new residents and information about any changes is passed over at handover and written in the staff communication book. One resident said, “I am independent, I have told them I want to do things myself and they don’t prevent me doing so”. There were sheets to record any healthcare appointments had in the care files and these showed that a doctor was called when it was noted in the communication sheets that a resident was not feeling well and another showed a resident was receiving ongoing treatment for leg sores from the district nurse team. The manager said where possible residents keep their own doctor and care files showed that residents are registered with different local practices. Where it is not possible to remain with their own doctor residents are able to choose which practice they register with, subject to them accepting new patients at the time. The manager said they access services through the local doctors including diabetic and community nurses. Services are also provided by opticians and chiropodists, although there is difficulty in accessing dental services. Staff said they take precautions to prevent spreading infection through using protective clothing and clean towels and flannels. Staff said residents who are able will tell them if they are not feeling well and they watch to see how they are looking. Staff said they see to things like St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 13 cleaning glasses for those unable to do so themselves as part of the daily routine. A resident said, “The optician comes to check our eyesight and a chiropodist visits”. Part of the morning medication round was observed and staff were seen following the correct procedures, including locking the drugs trolley when unattended and watching residents take their medication. Medicine Administration Records were fully completed and the manager was seen ordering medication for residents who needed it. The manager said only staff who have been assessed as competent to give out medication are able to do so and there have not been any reported drug errors. Staff that are involved in giving out medication said that they were familiar with the correct procedures and had been trained on them. A resident said, “They won’t go away until we’ve taken our tablets”. There was a reference seen in a care plan to meeting a resident’s privacy and dignity, but this did not explain how this was to be done. The manager said that practices in the home were designed to promote residents privacy and dignity, for example using a residents preferred from of address, residents being able to chose the gender and age of anyone who assists them with personal care and always knocking on doors before entering. The manager said training on promoting residents’ privacy and dignity will be provided in the future and that this is included in the home’s induction programme. Staff said they promote residents’ privacy and dignity by encouraging independence, explaining what assistance they are going to provide before doing so and preventing embarrassment. A resident said the laundry service had greatly improved since the home reopened and, “our clothes don’t get lost anymore”. St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 14 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 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ expectations regarding their social needs are not being met. Staff practices promote individual rights and choice. The food in the home is of satisfactory quality, well presented and meets the dietary needs the residents. EVIDENCE: The home has not got an activities organiser at present, but the manager said this is something she is in discussions with the provider about. There are some entertainers who visit the home and some relatives run a monthly bingo session. The manager said the activities programme is something that needs to evolve with the residents and sees it as an area of priority to work on. Staff said they did not think there was enough going on at present for residents to be kept occupied. St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 15 A visitor said her only dissatisfaction with the home was there needs to be more available for residents to do. A resident said, “We have been told there will be someone to organise activities when more residents have moved in, we would like thinks to do, at the moment we can read and watch TV”. The manager said that there are some residents who attend a local church and a local women’s fellowship. Residents are able to go out with their families and trips are arranged to rotary Club teas. Staff said that visitors are welcome at anytime and they are sometimes here until late at night. A resident said, “I am going out with my daughter this afternoon”. The manager said that apart from mealtimes, which are set, the home is run at the residents’ pace. Staff said that they encourage residents to be as independent as possible. A resident said, “Nobody makes us do anything, we can come and sit where we want or stay in our rooms” Residents were seen spending time in communal areas and in their rooms. Staff were seen asking residents what they wanted, for example the cook was asking residents if they wanted gravy on their dinner. The main meal is at lunchtime and dishes include beef stew and dumplings, sausage and onion pie, gammon with pineapple and a fry up. There is a different type of fish on Fridays and a roast dinner on Sundays. A lighter meal is had at teatime with a choice of a hot or cold meal. Meals include such things as salads, sandwiches soup or ‘something’ on toast. A pudding is provided at lunch and teatime. Lunch today was a choice of liver and onions or steak pie, leeks, carrots, mashed potatoes and gravy. The pudding was a choice of apple crumble and custard or fruit or yoghurts. Six residents were asked if they enjoyed the meal and all said they did. One resident said she had been given some chicken, as she did not like what was available. The cook said fresh fruit was available every mealtime, however a resident said she would enjoy having some fruit at other times in the day. There is a record made of which food residents like and dislike and the cook has information about any special diets residents require. St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 16 A resident said, “They asked me what I like and don’t like when I came, that was the best thing they could have done, I was worried I would have to eat something I didn’t like”. Staff said there is a good choice of food and residents who are able say they enjoy their meals. A resident said, “The food is very good, but I would enjoy some kippers”. This was passed to the cook who was later heard telling the resident he would get some for him. St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The procedures for managing complaints and safeguarding adults are not yet properly in place, although the principles of these areas are understood. EVIDENCE: The manager said there have not been any complaints made since the home reopened and that she views complaints as a positive way of receiving feedback and identifying areas for improvement. The manager said there was not a book for recording any complaints in but would be putting one into place shortly. Staff said that they would pass any complaints through to the manager, but were not really sure about what the procedure is as they had not had to deal with any. A visitor said she would feel at ease to discuss anything she was not happy with but did not have any complaints. A resident said, “If anything wasn’t right I would take it to the manager who would sort it”. St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 18 As the home has only recently reopened they have not received a copy of the new Adult Protection procedures. When this was pointed out the provider downloaded these from the Adult Protection website. The manager said there have not been any safeguarding incidents and that she will be booking places for staff to attend safeguarding adults training as part of the training programme she is compiling. A resident said, “I feel safe and secure in the home”. St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a safe, well-maintained environment, which is clean, pleasant and hygienic. EVIDENCE: The home was well decorated and there were no outstanding repairs noted. There has been some new carpets laid and the manager said more are on order and will be laid shortly. One of the care assistants has time allocated for carrying out routine maintenance and a handyman employed at another nearby home is available to assist with other maintenance tasks. St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 20 Staff showed a repairs book for recording any repairs they come across and these were marked off when completed. A resident said, “Any repairs are seen to and one of the staff is given time to help do things in our rooms, like put up shelves and pictures”. The home was clean and tidy and everywhere was fresh. There is a cleaner in the home everyday and a laundress 5 days a week. Other staff will do laundry at other times. The manager said training in infection control has been booked and will be provided soon. Staff were seen using protective clothing when providing personal care and said there are always plenty of supplies available. A resident said, “Everywhere is clean and tidy, my room is vacuumed practically everyday”. St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 21 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 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels allow for basic care needs to be met. Arrangements are being made to ensure that all staff are suitably trained. EVIDENCE: The manager has assessed their minimum staffing levels to be 3 care staff on duty at all times. In addition the home employs a cook, kitchen assistant, handyman and cleaners. The home employs male and female staff and they are of varying ages. Staff said there were enough staff on duty to see to the care needs of the residents, but this did not allow for them to organise any activities or outings. A resident said, “It would be nice to have someone to organise activities for us”. Staff files seen showed that the correct recruitment practices are followed. The home follows their equal opportunities policy in the recruitment of new staff. St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 22 One new member of staff had a Protection of Vulnerable Adults check but was still waiting for his Criminal Records Bureau check to be returned. As a result the member of staff should only work under supervision of another member of staff at all times, however the member of staff was seen on two occasions in a room with residents when no other staff were present. The manager raised this with staff concerned and the member of staff then remained supervised. Training records showed that four care staff have previously completed National Vocational Qualification level 2 and the manager said a further four were enrolled on this course. One member of care staff has achieved level 3. The manager said she is organising a training programme for staff to ensure that staff have the required training. The manager showed details of courses already booked and said that further courses are being planned. New staff complete the TOPPS induction when starting work in the home ands all staff are provided with supervision. St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is qualified and has the necessary experience to run the home. A formal system for residents to express their views on the running of the home is needed. There are appropriate arrangements to promote the health and safety of residents. EVIDENCE: The manager has been in post since the reopening of the home under the new provider and was registered in August 2007. The manager has achieved St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 24 National Vocational Qualifications levels 3 and 4. The manager held the post before under a previous provider. Staff described the manager as “fantastic” and a resident said, “She is very good, when I knew she was coming back it made up my mind to come back here after it was closed”. The manager said she has not yet had time to put the quality assurance systems into place but this is planned to be done soon. The manager said that they are not involved in looking after any money for residents. Staff said they do not handle residents’ money, this is done by relatives. A resident said, “I handle my own affairs” and another said, “My son deals with my money”. The manager said that all the required health and safety checks are carried out at the required frequency and there are service contracts in place for servicing all the equipment. It was stated on the Annual Quality Assurance Assessment that equipment is tested or serviced as recommended by the manufacturers or other regulatory body St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 St Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 OP3 Regulation 14(1)(a) Requirement Assessment documentation should be amended to allow for information concerning residents’ ethnic origin and any significant relationship to be obtained. Care plans must clearly describe how resident needs are to be met and where a need is identified a care plan must be written for this so that staff know how to meet residents’ needs. More frequent and varied activities must be provided so residents have opportunities to spend time doing things they find enjoyable and stimulating. Timescale for action 01/04/08 2 OP7 15(1) 01/04/08 3 OP12 16(2)(n) 01/04/08 4 OP16 17(2) 5 OP18 12(1)(a) The complaints procedure should 01/04/08 be promoted so that the process to make a complaint is know by staff and residents, and a record of all complaints is made. All staff must be familiar with the 01/04/08 procedures to follow to safeguard residents if there is any suspicion of abuse. DS0000070684.V359923.R01.S.doc Version 5.2 Page 27 St Saviours Care Home 6 OP27 18 (1)(a) 7 OP33 24(1) There should be sufficient staff on duty to enable residents’ social and recreational needs to be met. A formal system is required that enables residents to express their views on how the home is run. 01/05/08 01/05/08 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 Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Saviours Care Home DS0000070684.V359923.R01.S.doc Version 5.2 Page 29 - 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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