Inspection on 22/08/07 for The Minster

This inspection was carried out on 22nd August 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Minster 27/09/06

The Minster 13/02/06

The Minster 03/08/05

The Minster 09/03/05

The Minster 26/07/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 The Minster Mill Street North Petherton Bridgwater Somerset TA6 6LX Lead Inspector Barbara Ludlow Unannounced Inspection 22nd August 2007 12:45 The Minster DS0000059630.V347065.R01.S.doc Version 5.2 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 The Minster DS0000059630.V347065.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 Adults 18-65. 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. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Minster Address Mill Street North Petherton Bridgwater Somerset TA6 6LX 01278 661528 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) Voyage Ltd Care Home 10 Category(ies) of Learning disability (10), Physical disability (10) registration, with number of places The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 10 persons in categories LD and PD. Date of last inspection 02/02/07 Brief Description of the Service: The Minster is registered with the Commission for Social Care Inspection to accommodate ten service users with a learning disability and associated physical needs. The company Voyage owns the home. The home is situated in the village of North Petherton, near Bridgwater. The home can accommodate service users who require a bedroom on the ground floor. The home does not have a passenger lift to the first floor. All bedrooms are of single occupancy and have full en-suite facilities. The home is decorated and furnished to a high standard. There is a well maintained large rear garden with lawn and patio areas accessible from the house. The Minster is situated in the heart of the village and is close to all community resources such as shops, post office, church, pubs, chemist, doctors surgery, library and hairdressers. Fee range: £600 - £1400 per week. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. This inspection visit was carried out over a six hour period. The manager was on duty and gave her time to assist with the inspection process. The Annual Quality Assurance Assessment (AQAA) had been completed and was sent to CSCI before the inspection. Questionnaires were sent to service users, staff, relatives and visiting health care professionals. Their comments are included in the report. A tour of the premises was made. Residents were joined in the communal room and daily life at the home was observed. Mealtimes, both dinner and teatime were discreetly observed. Residents, staff and visiting professionals were spoken with during the day. Records were requested and sampled. These included the maintenance records and care plans. Feedback was given to the manager at the site visit. The inspector would like to thank all who contributed to the inspection process. What the service does well: What has improved since the last inspection? The requirements and recommendations made at the last random inspection visit have been addressed. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 6 There has been replacement of the shower room floor covering and one bedroom floor covering. Fire training had been addressed and only one person was identified that had not yet been updated. First aid training has been addressed for all staff. All bank account details now come directly to the resident at the home and the audit trail was clear. Care planning has received attention to reviewing and signing the care plans and risk assessments, this was being prioritised and carried out at the resident’s care review. What they could do better: 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. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good The admission process includes a detailed assessment prior to a place being offered. The prospective resident is invited to visit and spend time at the home. This process helps to inform the person’s choice and assist them with their decision making. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has had one new admission since the last random inspection. The case tracking process was used to assess the homes admission procedures and practice. There is information available to prospective residents and their families. Pre admission assessment is carried out carefully and consideration is given to assessing the potential resident in their present home. Relatives are seen and visits to the home are encouraged. The person seeking a place at the home would be invited to visit as often as they wish to meet the other residents, staff and to socialise with the group. Feedback was very positive and the inspector heard that residents felt they had made the right choice in coming to The Minster. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good Residents are supported in their daily living and decision making. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans were sampled. Residents were all seen and were spoken with during the day. There was a good atmosphere, staff and residents get along well together, mutually trusting and respectful relationships were observed. Good rapport was heard between residents and staff during the day. One new resident was seen and they shared their experience of moving into the home. The care plan had been tailored to meet their assessed needs preadmission. A key worker is appointed pre admission and is responsible for introducing the new resident to the home and the other residents on arrival. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 10 Residents have scheduled activities in a weekly programme. There is flexibility when a resident wishes a change. Individual decision making was seen where residents had chosen to go out with particular friends, this choice was supported by staff. Resident’s best interests and well being are considered regarding activities, trips out and any entertainment offered. Holidays away from the home are organised. Residents who are able also take holidays with their families. Over the next twelve months the home wants to develop care plans that are completed in more appropriate format for the residents. This will be followed up at the next inspection. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good There is a good range of activities and community events available to the residents. Families are welcomed and relationships are supported. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans were sampled and residents and staff were spoken with about daily life at the home. Individuals have activity plans that include their therapies and social activities. There is a weekly programme of activities that staff use as a guide to the week and this ensures that nothing can be missed. Those attending college are included in the daytime activity programme in the holiday periods; this was the case for one resident. Attendance at further education colleges where access to suitable courses and training is available is supported. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 12 Mixed social activities are supported by staff that have access to transport. Two minibuses are available and staff are trained to drive these. Social events and opportunities are displayed on the homes notice board. Residents may attend day centres and there are social day trips and visits. On the day of the inspection two residents and two staff went to Burnham on Sea for the afternoon. They reported having had ice cream and an enjoyable time. The garden is accessible from the double doors in the communal lounge area. These were open for most of the day and provide easy access to the garden space and patio. This is not an easy wheelchair access route. Families and friends are welcomed and there are no visiting times. The manager recently arranged a barbeque and invited families to attend. It was well supported and the manager hoped it gave an opportunity for families to meet other residents and to network, if they wished, with the other families. Family birthdays were recorded in the care plans. Residents also have money charts that hold a day to day financial record for them in their care plan. The home is situated in a quiet residential area within walking distance of a good range of shops. Mealtimes were observed, both lunch and at teatime. Residents can chose when and where they eat. Today meals were taken together in the dining room. The meal was relaxed and sociable but was orderly and there were no periods of waiting. The residents can choose and do influence the daily menu. Residents attend the kitchen serving hatch to collect their meal, add condiments and / or sauce and choose a drink from a choice of flavoured squash. Staff working through the day or evening took their meals with the residents. The AQAA indicated that the manager would like to make some changes for example introducing side plates and condiments to the tables. Information regarding the menu says residents can chose what they have to eat and that they take part in planning and shopping. One resident had been given a mixed salad and proceeded to remove a number of small pickled onions off their plate before taking it. There was no complaint heard but this should not have been added if her dislikes are known by the staff responsible for the catering. One very active resident appeared to be hungry and ready for their meal, another nearly managed to snatch a chocolate roll from a [person passing by. Care must be taken to ensure dietary needs are satisfied where activity and therefore calorie intake requirements are raised. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 13 Staff were asked if residents were weighed regularly as there were no recent weights recorded in the care plans sampled. The inspector was informed that this was because the member of staff responsible for weighing residents had been off sick. Management delegation of such responsibility is recommended. Where assistance was needed this was given sensitively and was well managed way. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good The residents are encouraged to be as independent as possible. Support with personal and healthcare is enabling and achievement was reported. Record keeping had improved and was person centred. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service users in residence were all seen. At the start of the inspection two residents had been taken out to lunch. Two residents were at their art class and a gym session had been cancelled leaving the residents for this class, at home. Activities for the afternoon were planned. A tour of the premises was made and one resident was seen in their room, another took the inspector to see their room. Bedrooms were homely and a reflection of the residents interests. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 15 Staff and residents redecorate bedrooms together when necessary, this had been creatively achieved in two of the rooms seen. One staff said they had shopped to find accessories to meet the design and colour choices made by a resident. Lunch was observed in the dining room. Eight residents were served and assisted by two staff and the manager. A burger in a bun was served with chips and onion rings and sauce. Yogurts were given as a dessert. Choice was offered and non verbal communication was observed to be skilfully used by the manager and staff with one person to ensure they had the lunch they wanted. Residents had degrees of prompting and encouragement, one person was assisted throughout. This was all sensitively done. The visiting massage therapist came in after 2pm to see three residents. There is no extra charge for this service. Care plans were sampled in detail for three residents. The care plans were very detailed and held personal information and family contact numbers. Key workers were identified and it was pleasing to see that where it had been appropriate there had been a change made in the resident’s best interests. A single assessment process review was in place; this indicated good progress had been made since admission. The resident agreed with this also feeling they had grown in independence and confidence since admission. A flow chart is used in the care plans to assess mental capacity in line with the Mental Capacity Act. The care plan includes a missing person report for use in an emergency. Risk assessments had been made and were on the care plan file. The care plans are written in a person centred way. Complex pre admission assessment was seen on one file. Reviews of the care plans were regularly made and were up to date. One service user responding in writing indicated that they were more motivated living at this home. Relatives who responded in writing indicated that they are pleased with the care of their relatives. One care plan demonstrated regular input from a hospital and regular daily prompting by staff to enable them to input and some control in the management of their health condition. There was evidence of dental health check ups, treatment and chiropody care. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 16 Weights were not recorded for one person since December 2006, another was February 2007, this must be addressed. Care must be taken to ensure dietary needs are satisfied where activity and therefore calorie intake requirements are raised. See also Lifestyle. Photographic ID was present on the care plans. Medication management was checked with a member of staff, the records were sampled and were up to date and the storage was satisfactory. GP feedback was positive. Service users attend surgery if they need to (next door) support given as necessary. Bedroom doors are lockable for privacy. Staff policy guidance says knocking on bedrooms doors and respecting the care home as the person’s home is expected and it reminds staff that this is their place of work. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good The management of the home have systems in place to enable them to deal with feedback and complaints in a professional manner. Recruitment is managed centrally and there are Criminal Record Bureau (CRB) checks in place for all staff. These processes help to protect the residents from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints policy and residents and their families are informed about this, it is also in the Service User Guide that all residents are given. There had been no complaints made to the home or to the Commission for Social Care Inspection. Recruitment was sampled; there was evidence that CRB checks had been taken up for newly recruited staff. Residents asked said they felt able to raise any concerns with the staff at the home. Families also commented positively about feeling able to raise any concerns with the home. The AQAA stated that the company have a policy entitled ‘letting us know what you think’ and gather any concerns this way, the residents are issued with help cards. There is a whistle blowing policy in place for staff. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good The Minster is a comfortable and well maintained home; it provides a safe and pleasant environment for the residents to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Minster is a comfortable and well maintained home; it provides a safe and pleasant environment for the residents to live. The entrance hall is secure and using a keypad opens onto the small car park at the front of the house. The minibuses are kept here. Car parking for visitors and staff is also at the rear of the house in a designated area. There is a large lawned garden and patio area. The communal lounge, which is nicely furnished, has doors opening onto the garden, visually extending the The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 19 house into the garden. The doors were left open at this inspection allowing residents to have fresh air and be able to go out into the garden. The dining room has a hatch servery and is spacious and well used. A new shower room has been fitted since the last inspection; this was a good addition to the facilities. Bedrooms without exception were clean and comfortable. Residents can lock their doors and there is respect for privacy recognised by staff and residents. The en suite in one bedroom is subject to extra cleaning and still has an underlying odour. The staff are aware of this and make extra efforts to manage this. There is no air extraction from this room as it is not on an outside wall and has no windows. The laundry equipment is sufficient. The cleaning is managed by one cleaner and all the staff do some housekeeping. Residents are asked to tidy their rooms. The night staff also have some cleaning duties. The kitchen is not accessible to residents. There is separate night staff sleeping accommodation. The home manages infection control well; a recent gastric infection was well managed and contained. Notifications were made and good infection control practices were reinforced to achieve this. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good The home has a staff ratio that works well during the week. Care must be taken to ensure staffing ratios are sufficient at the weekend to sustain the good level of care delivery. Staff recruitment check lists seen, were incomplete. The manager confirmed the checking of evidence of safe recruitment practices to protect the residents from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA states that the company has appointed a head of learning and has identified regional training managers to improve the training and development of all staff. Staff recruitment is handled centrally and a sheet is held in the home with recruitment details on it. CSCI had agreed that the records could be held centrally. The record sheet for two new staff was sampled on 24th September 2007 by arrangement with the manager. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 21 This form had the necessary headings but for one the second reference was not recorded and the second had no POVA date and no CRB number. The manager confirmed having checked at head office for the missing reference and informed the inspector that this was due to the reference being e mailed, this was not recorded. The record held at the home was inadequate and did not demonstrate that a safe central system of recruitment was in place. Subsequent to this inspection the inspector has been informed that the company is addressing this deficit in some of its homes records. Staff had received training and induction and records of recent training and supervision were sampled at the inspection. Staff had good relationships with residents and interacted in meaningful, supportive and caring ways. There was mutual respect and the residents were relaxed and comfortable around the home. Feedback forms were received from 5 staff, these gave a positive reflection on staff management. This feedback confirmed that staff were confident in their work. They had received training, supervision, knew their clients, had access to protective clothing. They confirmed having had CRB checks. Two of the respondents were enrolled to undertake NVQ training, two others were not and one already had an NVQ Level 3 in care. Staff are named key workers for residents and this entails offering more involvement and support to that person from their admission introductions onwards Staff are involved with all aspects of care from personal, social, cleaning and catering. Holidays are arranged for residents and staff go along usually as a ratio of one to one. There are usually six staff in the daytime and four from 6pm in the evening. The feedback indicated that weekends are hard work when the staffing ratio goes down to 3 or 4 in the afternoon. Fire training was overdue for one member of staff and this was to be organised after the inspection. First aid risk assessment is recommended in line with the most recent guidance. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good The home is being well managed and is safely maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) had been completed and sent to the inspector before the inspection visit. This was detailed with a good level of information. Aspects such as evidencing what the home does well and explaining how the home plans to develop in the next twelve months were clearly stated, the goals appear to be realistic. The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 23 Time was spent with the homes manager. Management systems are in place and there was evidence of some improvements having been achieved since the last inspection. The home has been well adapted to meet the needs of the residents. The environment is well maintained and homely. The home has fire safety systems and these are regularly maintained. The kitchen was clean and is well managed; there is restricted access for the safety of residents. Hot water is regulated to a safe temperature at bath outlets, the last checks were done on 18/08/07 and these were in the safe range. Weekly fire alarm tests had been carried out and the emergency lighting was checked on 19/08/07. Staff fire training records were examined and one staff was identified that required a six monthly update. The fire brigade had carried out a fire safety audit in January 2007. An evacuation check was made on 13.08.07. Portable electrical appliances were checked on 22.03.07 Gas safety checks were made 12.05.07 Cleaning chemical (COSHH) records are maintained and were available in the office. The home was displaying the registration certificate and certificate of Employers liability insurance. First aid training had been given to staff; one person only now has this training outstanding. All records are safely stored and securely managed. The Minster DS0000059630.V347065.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 25 NO 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 YA34 Regulation Requirement Timescale for action 05/11/07 19(1)(b)(i) Staff recruitment information Schedule must be recorded in sufficient 2 detail at the home to demonstrate that a standard of recruitment practice is maintained centrally that will protect service users from harm. 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. 2. Refer to Standard YA33 YA17 YA19 Good Practice Recommendations Staffing levels at the weekend should be reviewed to ensure they are maintained at a good level. Regular monitoring of weight should be carried out and recorded to determine whether or not nutritional needs are being met. Risk such as high activity and higher energy needs may not be identified if weight is not monitored. The provider should work towards the standard of 50 of the staff being trained to NVQ2 in care or equivalent. 2. YA32 The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 The Minster DS0000059630.V347065.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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!