Inspection on 06/09/07 for St Wilfrid`s Care Home

This inspection was carried out on 6th September 2007.

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

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

Other inspections for this house

St Wilfrid`s Care Home 25/09/06

St Wilfrid`s Care Home 21/02/06

St Wilfrid`s Care Home 18/10/05

St Wilfrid`s Care Home 15/03/05

St Wilfrid`s Care Home 19/07/04

St Wilfrid`s Care Home 23/03/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE St Wilfrid`s Convent 29 Tite Street London SW3 4JX Lead Inspector Ann Gavin and Wynne Price- Rees Unannounced Inspection 6th September 2007 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 Wilfrid`s Convent DS0000010850.V337725.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 Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Wilfrid`s Convent Address 29 Tite Street London SW3 4JX 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) 020 7351 5339 020 7376 5539 The Congregation of the Daughters of the Cross of Liege Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th September 2006 Brief Description of the Service: St. Wilfrid’s Convent is a large purpose built residential home for up to 44 older people located in an attractive area of Chelsea. The proprietors are The Congregation of the Daughters of the Cross of Liege. Sisters of the order live in an attached annex. The home comprises of five floors, the lower ground floor provides a lounge/conservatory and a dining area, the main kitchen and laundry. The ground floor main entrance leads to the reception area, this floor comprises of a communal lounge, the managers office, several meetings rooms and administration areas. The upper floors provide single bedroom accommodation, and all are provided with ensuite facilities. Small lounges are located on each floor, as are specialist bathing and toilet facilities. Three passenger lifts and two internal staircases provide access to the upper floor of the home. To the front are well landscaped and maintained gardens. The fees range from £600 to £770 per week St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection with two inspectors on Thursday 6th September from 9.30 am to 4 pm. This report is made up of information gained from speaking with residents, staff, and managers as well as looking at records, tracking the care of four residents and a tour of the communal areas of the home. The information provided by the manager in the Annual Quality Assurance Assessment (AQAA) was also used. There were 16 residents, 3 relatives/visitors and 3 professional questionnaires returned. Their comments have been included in the report. The inspectors would like to thank the residents, managers and staff for their welcome. What the service does well: What has improved since the last inspection? What they could do better: St Wilfrid’s must continue to further develop the individual care plans together with the residents. They need to create a more accessible format for residents and staff with a greater focus on people’s personal history and profile. Equally to develop their recording of people’s personal interests and their plans for more individual activities. St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 6 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 Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 (standard 6 is not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information available St Wilfrid’s is being updated. There are new good procedures for assessing people’s needs before they move into the home. Everyone has the opportunity to visit the home proper to admission. EVIDENCE: ‘All prospective Service Users are encouraged, whenever possible, to view the home, meet the staff, sample a meal, join in an activity and stay for a trial period.’ (Extract from the Annual Quality Assurance Assessment (AQAA) self assessment completed by the manager) ‘I visited before coming and had a six week trial run…’ Quote from resident St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 9 St Wilfrid’s have both a web page and a brochure to describe the care and services offered in the home. The new manager is working on updating these. Everyone who wishes to move into St Wilfrid’s has an assessment of their needs completed by the manager, the head of care, or deputy. The format used has been updated to a comprehensive assessment covering all areas of health and social care. The assessments seen were good and informative. All people who have been admitted recently have been given a new more personalised contract and terms and conditions. St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents felt their care needs were met in a respectful and dignified way. There has been a review of medication and healthcare profiles. St Wilfrid’s are continuing to develop care plans to become more accessible for residents and staff. EVIDENCE: ‘St Wilfrid’s is a very good residential home. The residents are well cared for physically and pastorally ……the standard of care for sick or disabled residents is extemporarily ‘ ‘ I think they try their very best and ensure that their older residents are as dignified, happy and well care for as possible..’ Quotes from local G.P’s ‘ Information sharing about my relative is getting better’ ‘They make my relative feel welcome and secure and subsequently happy..’ Quotes from relatives ‘Care staff look after me well… ’ Staff are very nice, very discrete…’ Quotes from residents St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 11 The care of four people was reviewed through discussions with them, with staff and through looking at their care plans. Everyone felt the care they received was good that the carers were respectful and treated them with dignity. The care plans have been added to since the last inspection. However the system remains complex. It is difficult to access information and it is not geared to promoting a personalised plan of care that is created together with the resident. There was some evidence that people have been involved in planning their care. A simpler more accessible format that gives greater focus to the personal history and profile of the resident needs to be developed. The care plan could then be kept in the person’s room. Each care plan had a risk assessment that had been updated as circumstances changed. The format of these assessments is also being reviewed together with the care plan. A risk assessment for a person who smokes was seen. The residents together with the manager and staff have agreed to designate one of the lounges as a smoking area. One of the residents asked the inspector about being able to smoke in the garden which has not been permissible to date. The manager and sister superior will review this decision for residents. Selecting an area, in the garden, where other residents would not be disturbed with the use of a water ashtray were suggested as ways of meeting all residents’ needs. St Wilfrid’s have completely reviewed their medication procedures. These are now rewritten along with a new medication policy. They have also changed their pharmacy supplier. The new pharmacist is working closely with the staff and will provide quarterly audits and training. The medication system was clear,with typed MARS (Medication Administration Record Sheet) that contains all the medication to be dispensed.The sheets were well kept with no gaps. St Wilfrid’s has employed a care consultant with a nursing background to support changes with medication and healthcare profiles. They have been able to deliver teaching sessions on the policies and procedures and work alongside the staff to ensure competency in the new system. The recent in house mediction audit showed very good results. The controlled drugs are kept as required with two staff members signing and carrying out a daily checks at the end of each shift. There are updated photographs of residents in their medication files.Two people are currently self medicating. They have completed and signed an assessment.They now also have small lockable cabinets in the bathroom to store their medication. There are good contacts with the G.P. and district nurses. St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 12 St Wilfrid`s Convent DS0000010850.V337725.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): 12-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Wilfrid’s offers a wide range of social events and activities. People are encouraged to maintain their independence and follow their cultural religious and social preferences. They are developing more individual activities. The menus have been reviewed and more fresh fish, vegetables and homemade produce have been introduced with good success. . EVIDENCE: I think the food could be simpler and not ‘mashed up’ ‘ The food is marvellous…’ ‘Sometimes too many activities. Sometimes there is no time to do my personal things..’ ‘I would like to do painting they don’t do painting here..’ Quote from residents St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 14 ‘St wilfrid’s have been such a help to my relative and her family. Everyone has been exceptional and my relative is so happy…’ ‘Cheeful consitent care..’ ‘ it would be appreciated for something to allievaite the boredom of residents who can’t read etc could be arranged...’ ‘ There is an atmosphere of love,care and spritual support….’ Quotes from relatives St Wilfrid’s has developed a good selection of group social activities both within and outside of the home drawing on a large volunteer network. They have contact with The Royal College of music who provide concerts and have open access to the Physic Gardens. Coffee mornings are held in the Royal Hospital. This is one amongst many other events. There is a calender of events displayed. There is a large room for social activities, a library, television room and quiet rooms. The manager said that one of the lounges has been dedicated for activities. It has been planned that a member of staff is availble to offer any assistance. A group were meeting for scrabble on the day of the inspection. St Wilfrid’s have just appointed one of the carers as a full time activity coordinator to work alongside the sister who has led all the social events on a voluntary basis up to now. They will take up their post in October. Currently there is little information recorded of people’s personal interests this needs to be developed along with plans for more individual activities. Discussing with the manager it is planned that the Activities Co-ordinator will focus on developing a personal assesssment for each resident and a daily plan to meet their social, cultural and spiritual needs. They will also develop more individual activites for people. The manager also plans to train staff specifically to recognise all activity based care and the importance of documenting it in the care plan. The ethos of St Wilfrid’s is focused on meeting the diverse spiritual needs of residents. Residents spoken with and the feedback from questionaires confirmed this. The manager has introduced an informal monthly meeeting with residents over a sherry before lunch. There has been a high reponse and residents have been happy to talk about things informally and exchange ideas. St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 15 There was a residents forum earlier in the year and these will be held regularly. The manager plans to develop the residents questionaires and to create a more structured way for residents to give feedback and to input into varoius aspects of the home. Since the last inspection there is a new hairdresser at St Wilfrid’s who visits weekly.There is a hairdressing salon. The residents are happy with the quality of the service and the fact that there are now fixed prices. Residents spoke well of the food and the introduction of more homemade items and fresh fish. The manger said they have changed their food suppliers and have included more fresh fruit and vegtables as well as fresh fish onto the menu. The chefs do not meet the residents on a regular basis and there is no regular formalised format for residents to input into creating the menu. However it is planned that the chef will met all new residents on admission to see what foods they prefer. They will also meet the other residents on a regular basis to get a more personalised feedback and to gather ideas for future menus. Currently ideas for the menu come from the residents meetings. There has also been a greater emphasis placed on supporting people discretly in the dinning room. There had been concerns raised that staff did not actuivly support residents who might require assistance or encourgaement during meal times. Now the staff sit alongside residents when needed and there is always a senior member of staff in the dinning room to ensure that residents receive the appropriate support. The staff were observed supporting residents at lunchtime.One resident was enjoying lunch with a relative. There was an unhurried airand ersidents appeared relaxed and able to go at their pace. People can be served meals in their room and request early breakfast as was observed on the day. St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 16 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are complaints and adult protection procedures in place. EVIDENCE: ‘ There needs to be a handbook which includes how to complain… Quotes from relative There is a written complaints procedure that residents’ spoken with confirmed they have been made aware of although if they had a complaint they said they would generally discuss it with staff first to resolve rather than initiating the formal procedure. There are also complaint recording forms that meet the standard although the home is redeveloping them to make them more user friendly. There are currently no outstanding complaints. Complaints are incorporated within the quality assurance system to identify any trends and consider ways to improve the service. St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 17 There are currently no adult protection issues and staff have received adult protection and abuse identification training. They are also aware of the procedure to follow if abuse is encountered. The recruitment procedure incorporates CRB and POVA checks with no staff allowed to work unsupervised until clearance has been received. St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 18 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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual and communal accommodation is in good decorative order and well maintained. EVIDENCE: ‘Cleanliness – it is always immaculate…’ Quotes from relatives St Wilfrid’s is a modern attractive home. Accommodation is arranged over the first and second floors. Each floor has a small lounge and kitchen. There is also a library, smoking and non-smoking lounge a conference/ activity room and a conservatory. A gardener maintains the attractive gardens. St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 19 Resident’s bedrooms are all provided with en suite facilities, and are individually decorated. A tour of the premises demonstrated that the home is fit for its stated purpose and was clean, secure, tidy and well maintained. The top floor has been refurbished and other floors scheduled to be upgraded as part of the maintenance programme. The home has beautiful communal gardens that a number of residents were enjoying during the inspection. Residents spoken with said they were satisfied with the accommodation provided. St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 20 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): 27-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an efficient and friendly staff team that are suitably skilled and qualified to meet residents’ needs. EVIDENCE: ‘Generally good care and friendly staff…’ Quote from Relative I consider everyone with whom I deal is always helpful Quotes from residents The home has re-structured the staff rota to provide an extra waking staff member at night and the rota demonstrated that there are suitable numbers of staff on duty, at all times to meet residents’ needs. Whilst carrying out their duties efficiently observation of care practices also showed that staff approached their responsibilities in a caring and friendly way. Staffing levels have increased during busy periods throughout the day. St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 21 There is a staff handbook that outlines roles, responsibilities, conduct and expectations. New job descriptions have been developed and are being distributed. Terms and conditions are being updated and scheduled to be issued within the next three months. This is being carried out in consultation with staff. In the interim a covering letter has been sent to staff outlining changes to conditions. There are currently two vacancies for fulltime carers and interviews are taking place. The recruitment procedure being followed was outlined verbally by the Care Manager and met the requirements of the standard. The steps taken were also recorded although there is no current written procedure. This is being developed. A sample of five staff records were inspected and the information required to be kept was on file. The home has achieved 69 NVQ level 2 qualified staff. There are two NVQ assessors in post. Full induction is provided with a training pack that incorporates manual handling, fire evacuation, health and safety and basic food hygiene. The home also operates a rolling training programme that includes dementia, adult protection and medication administration. Infection control training is also being developed. Training needs are identified during bimonthly one to one supervision sessions. Training provided by the local authority is also utilised. St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 22 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): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Wilfrid’s has a strong ethos of care. There is an experienced manager in place who has a clear vision for the development of the home and increasing the involvement of the residents. EVIDENCE: ‘Since coming into post on the 1st of May 2007 I have as far as possible, established that all the appropriate service contracts are in place, to ensure staff and residents health and safety…’ (Extract from the Annual Quality Assurance Assessment (AQAA) self assessment completed by the manager) St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 23 The manager has been in post since May. They have come from a nursing background and have been a registered manager of a large care home with nursing. They are in the process of registering with the Commission this needs to be completed. Since starting at St Wilfrid’s they have worked hard at setting goals together with the staff and residents to enhance the level of care. They initially focused on health and safety matters and medication and now plan to develop the personal care plans and risk assessments. They are clear about their own role and the delegation of responsibilities amongst the managers and staff. They have shown a commitment to involving residents in all aspects of the home. Residents are given the choice to manage their own finances and about five people do so. The new manager has set us a clear system to audit individuals accounts. Staff records confirmed that COSHH is incorporated in the health and safety training staff receive. A fire officer visited and made recommendations that have been implemented in the event of fire and a copy of the building plan is now kept at the local fire station. All fire doors have been fitted with automatic closures and there is a designated fire marshal. The fire fighting equipment was checked and serviced in June 2007 and appropriate evacuation signs on display. Emergency lighting is checked weekly and regular fire drills take place. The call system is tested daily and hot water temperatures weekly. PAT tests are carried out on admission and then annually by an outside contractor. These records were not available for inspection as the contractor held them. There were health and safety risk assessments in place that were up to date or under review and an accident and incident book kept. There are weekly management meeting attended by all department heads where all aspects of the home are discussed. The home has a quality assurance system containing performance indicators and trigger levels that enable it to review service delivery and make any required improvements. St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 24 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 3 3 3 X X X 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 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement St Wilfrid’s must continue to review and develop care plans into a more easy to access format. There needs to be a greater focus on people’s personal history and profile. Residents must be involved in creating and reviewing their care plans. St Wilfrid’s must develop their recording of people’s personal interests and their plans for more individual activities. The new manager evidenced that a clear procedure for recruitment is in place. This procedure needs to be put in writing. St Wilfrid’s must complete the planned training for staff in completing assessments of social care and risk management The manager must complete their registration with the Commission. The records of pat tests must be provided to the Commission for inspection Timescale for action 31/12/07 2. OP12 16 30/11/07 3. OP29 18 30/11/07 4 OP30 18 30/11/07 5 6 OP31 OP38 8 23 30/11/07 31/10/07 St Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 26 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 Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Wilfrid`s Convent DS0000010850.V337725.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!