Inspection on 29/11/05 for Acocks Green Nursing Home

This inspection was carried out on 29th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Acocks Green Nursing Home 05/06/07

Acocks Green Nursing Home 22/06/06

Acocks Green Nursing Home 21/09/05

Acocks Green Nursing Home 09/03/05

Acocks Green Nursing Home 26/11/04

Acocks Green Nursing Home 16/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Acocks Green Nursing Home 1079-1081 Warwick Road Acocks Green Birmingham West Midlands B27 6QT Lead Inspector Lisa Evitts Unannounced Inspection 29th November 2005 08:30 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 Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 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. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Acocks Green Nursing Home Address 1079-1081 Warwick Road Acocks Green Birmingham West Midlands B27 6QT 0121 707 2611 0121 707 6549 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) Southern Cross Care Management Limited Mrs Petra Thompson Care Home 56 Category(ies) of Old age, not falling within any other category registration, with number (56), Physical disability (56), Physical disability of places over 65 years of age (56) Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Older people requiring nursing care Service users in category PD over 55 years of age and the older persons receiving residential care are over the age of 65. 21st September 2005 Date of last inspection Brief Description of the Service: Acocks Green Nursing Home provides 24-hour care for older adults aged 55 and over. It is a purpose built home and is situated in a residential area of Birmingham, close to a local shopping centre with all amenities including public transport. The home has two floors and accommodation consists of single rooms with some en suite facilities. There are two double rooms available and communal space consists of two large lounges on the first floor and one large and one smaller on the ground floor. There is an attractive garden situated to the side and rear of the home with a patio area and garden furniture for residents to access weather permitting, and car parking is available at the front of the home. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken by two inspectors over a full day when there were forty-seven residents living at the home. Information was gathered from speaking with the residents and staff, observing the care staff perform their duties and from examining care and health and safety records. A tour of the premises was also undertaken. This is the second statutory inspection for the year 2005-2006 and it is recommended that this report is read in conjunction with the previous report. At the time of the last inspection report, there had been a number of complaints raising issues about aspects of resident’s health, safety and care delivery, and this led to a short period, where there were no further admissions into the home, which allowed for the management to rectify the problems. Part of this inspection was to assess any progress made following these concerns being identified. It is pleasing to note that the management have put structures in place to address the areas of concern and are monitoring the service provided. Not all of the previous requirements made were assessed on this occasion. What the service does well: What has improved since the last inspection? Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 6 Conflicts between staff have been addressed in order to prevent a negative impact on care given to the residents. The management structure has been improved and now includes a deputy manager, team leader (who will work alongside the care staff) and senior care staff, in order to assist the manager to meet the care requirements of residents living in the home. A full time administrative assistant has also been recruited and will commence employment shortly. The manager has implemented the sending of acceptance letters to prospective residents, so that residents know that the home can meet their needs, prior to admission. The management have worked to address many of the requirements made from previous inspections. A new accident and incident reporting procedure had been implemented at the home and this ensures that the manager sees all accident reports each day. Accidents are audited on a monthly basis and this will help to monitor any trends or patterns to enable these to be rectified. What they could do better: Residents must be supported to wear clothing appropriate for the time of year, and in accordance with their personal preferences. Pre admission assessments must be fully completed to ensure that the home can determine if they can meet the needs of the resident prior to acceptance in the home. Bedroom doors must not be propped open, as this is a potential risk to residents in the event of a fire. Bathrooms and toilets must be kept hygienically clean and be in full working order, for residents to use safely as required. Care planning needs significant improvements to ensure that staff are aware of the individual needs of the residents and any changes in their care requirements, and to allow for the home to demonstrate that the care is being delivered to the residents. Staff approach and attitudes to residents must be addressed, to ensure residents are comfortable and feel safe in their environment. Residents and staff must be made fully aware of the complaints system, to ensure that residents report any concerns and that staff take the appropriate action. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 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 Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 5 The assessment and admission processes are generally comprehensive and ensure that the home can meet the needs of the individual prior to acceptance into the home. Contracts detailing terms and conditions are not available to all residents. Prospective residents are invited to spend a day at the home, enabling them to make a choice about whether or not they would like to live in the home. EVIDENCE: The home is currently in the process of reviewing contracts of terms and conditions for residents stay, as previously these had not been issued to all residents. Senior staff complete comprehensive pre admission assessments and these were found on files reviewed. Part of the assessment process involves the formulation of a draft care plan, this had not been completed for the most recent admission into the home. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 10 The manager has implemented the sending of acceptance letters to residents, following pre admission assessments and this ensures that the residents know the home can meet their identified needs prior to moving into the home. There was evidence that the most recent admission into the home had spent a day at the home and had lunch with the other residents, prior to moving in, so that they could see if they liked the home. Care reviews have been completed for all current residents at the home, to ensure that the home is able to meet their individual needs. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 Improvements are needed in the homes systems to ensure that resident’s health and personal care needs are met consistently. EVIDENCE: Care plans were not written in good detail and did not give enough information for care staff to ensure that individual care needs are met. Some specific preferences were recorded but this was not consistently recorded on all files. Care plans are evaluated however there was no evidence that the resident or their representative had been involved in the process. Daily reports were recorded in good detail, although it was not always evidenced that the nursing staff had followed up identified problems and made the appropriate referrals as requested by the previous nurse on duty. One resident in the home should have received fluids, which had been thickened to help with swallowing difficulties, however evidence recorded suggested that the home had run out of this and the resident had received drinks without the thickener. This is a serious risk to the resident’s safety and the manager must ensure that staff have ordered stocks through the GP prior to running out. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 12 One nurse was spoken to regarding care plans of the residents, however she was unable to give comprehensive answers about the care required by individual residents. This was concerning, as she was responsible for the care of the residents on that floor and for ensuring care staff implemented appropriate care practices. A recent admission into the home had three weight charts in place and it was confusing as to which chart was the most recent one. Some residents were not being weighed, as staff were unable to use the current scales. A requirement was left with the manager to provide appropriate equipment for weighing residents who are bed bound or unable to sit on the scales. There were many entries in the daily reports of a recent admission to the home regarding back pain, however no care plan was written in respect of this. Instructions from doctors had not been incorporated into the plans of care. Wound care plans did not always identify the type of dressing to be used. Care plans detailed the type of pressure relieving equipment to be used. Not all of the standard care planning documentation was relevant for all residents and it is recommended that information that is not applicable for every resident be removed from the individual care plans for ease of auditing. Visiting healthcare professionals visits are recorded on a separate page for ease of monitoring. However, on one file there was no evidence of any visits recorded since January 2005. Risk assessments were confusing and some contained information that should have been in the care plans. The manager received a requirement that assessments, care plans and risk assessments of all residents in the home are reviewed to ensure they reflect current care needs of the residents, and that all staff are aware of how to use the care plans. The majority of residents appeared to be well supported to meet their hygiene needs, however one resident was observed to be wearing odd slippers, one resident had long fingernails and was holding stained pads to help with contractures. Several residents were observed not to be wearing any tights or stockings and the manager received a requirement that residents are dressed appropriately for the time of year including tights or stockings as the resident chooses. During the tour it was observed that one resident had a jug of water in his room but there was no glass available. Staff must ensure that residents are able to access their drinks as required. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Residents are not always given the opportunity to exercise choice and control over their daily life. EVIDENCE: On display in the main reception area were details of the planned events for the Christmas period, which included Tombola, Christmas quiz and a Christmas party. During the last inspection, it was observed that a children’s television programme was on the television in one of the communal areas. It was pleasing that there was no evidence of this throughout the inspection and the manager stated that particular attention is paid to this during the walk rounds by senior staff. There is an open visiting policy and the home now plans to display the name of the person in charge of each shift, in the foyer, in order to improve communication between visiting healthcare professions and relatives. One resident stated that “the nurse comes and you’re up”. Following further discussion it became apparent that the resident didn’t feel that she had a choice when she got up in the mornings. This was further discussed with the staff who said that approximately fifteen residents are Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 14 assisted out of bed by the night staff, on the first floor. This must be reviewed by the manager of the home and reflected in the resident’s personal care plans, to ensure it is their preference to be out of bed early in the mornings. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The complaints procedure is comprehensive. At the time of the inspection it was noted that not all of the residents had used the procedure to express concerns, therefore it could not be guaranteed that all complaints are addressed. EVIDENCE: The organisation had produced a comprehensive complaints procedure and this was on display in the home. At the last inspection there had been a number of complaints made regarding the service provided by Acocks Green Care Centre, however it is pleasing that the Management team had addressed the majority of these issues and are closely monitoring the service provided at the Home. CSCI has received two complaints pertaining to the service since the last inspection and the elements of these complaints have been upheld and partly upheld. The management have addressed complaints previously raised, however on discussion with the residents, one stated that she “had lost a beautiful cardigan, as it never came back from the laundry” and another stated that “my magazines go missing”. On discussion with the manager she was not aware of these issues and this raises concerns as to whether residents may not be aware of or are reluctant to use the complaints procedure, or that staff are not reporting issues raised to Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 16 the manager. The manager will need to review this area ensuring all residents and staff are aware of the procedure. The CSCI was informed that an intruder had previously been found in the home. The code to the front door has been changed and is no longer given out to relatives and visitors, and staff have to let visitors into the home, to ensure the safety of residents. The adult protection policy was not reviewed on this occasion. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Residents are provided with a homely and comfortable environment in which to live, with the exception of washing facilities within the home. Toilet and bathing facilities need attention to provide adequate facilities to meet individual’s needs. EVIDENCE: The home was decorated with trimmings and trees for Christmas; dining tables also had small decorative trees as centrepieces. There are four lounges and two dining rooms and these are decorated to a high standard, with the exception of the small lounge on the ground floor, which requires the lower half of the room to be redecorated. There are four assisted bathing facilities and two shower facilities. One shower room was found not to be draining properly and there was a pool of water on the floor, posing a potential slip hazard to residents. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 18 The second shower room was found to be very musty and the manager received a requirement to ensure that both of the shower rooms were in full working order. A number of extractor fans were found to be dusty and not working and the manager received a requirement to audit all the extractor fans and ensure that they are clean and in working order. A number of communal bathrooms and toilets were found to have toiletries and opened pots of cream stored and this poses a cross infection risk. The manager received a requirement that all toiletries were to be removed from the communal areas and returned to the residents to whom they belonged. A toilet doorframe, shower chair and commode was found to be soiled, and the manager received a requirement to ensure that all areas of the home are kept clean. Two toilets were found to have cracked toilet cisterns and one bath chair was also cracked, this poses a potential risk to residents and therefore needs addressing to ensure they are repaired or replaced. One toilet had had a raised seat placed on top of the toilet bowl, however this had not been secured and would have moved if sat on, causing a risk of falling to the residents. Residents rooms seen contained personal possessions and one resident said, “My room is beautiful” One residents room had the bed against the wall, the resident required the use of a hoist and the manager must ensure that the residents rooms are laid out in order to minimise any risks to the residents and the staff during moving and handling procedures. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Adequate staffing levels are maintained at the home to meet the identified needs of the residents. EVIDENCE: Currently the home has vacancies for two care assistants and the manager is hoping to recruit into these vacancies in the near future. Nine care staff are on duty throughout the morning, eight care staff throughout the afternoon along with two trained nurses. The deputy manager has recently been appointed and will work as the third nurse to supervise and monitor trained staff. A Team Leader has also been appointed and she will be working alongside the care staff and be advising on actual care delivery. It was pleasing to see during the inspection, care staff were being guided on best practice by the team leader and although she had only been in post for a short time, she appeared to have a good knowledge of the residents care requirements along with the more general running requirements of the home, such as deliveries of supplies. The senior carer role is also being developed with the implementation of six senior roles. Each senior carer will have a designated area of responsibility. In addition to care staff the home also employs domestic, laundry, kitchen and maintenance staff. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 20 Comments from residents included: “Carers are lovely” “Staff come reasonably quick” “Some can be very blunt, others are absolutely gorgeous” “Staff are rough with me” Resident comments were discussed with the manager at the time of the inspection and these areas must be addressed. It is required that the staff receive training in customer care. At the last inspection there had been a number of concerns and complaints made about staff conflict. These now appear to have been resolved by the organisation and processes have been put in place to allow the staff to voice any concerns and the appropriate action to be taken. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 38 The organisation has implemented a structured managerial system in order to address the concerns previously identified. A programme of staff training is in place, which will need to be extended and rolled out to all staff to ensure they have the knowledge and skills to care for residents. EVIDENCE: The Registered Manager is a Registered General Nurse and has had much experience in caring for older people and has a Diploma in Management Studies and a Masters Degree in Business Administration. Since the last inspection, a Deputy Manager has been appointed at the home and the manager stated that he would initially, be concentrating on the care planning for the residents identified needs. Administrative support is currently provided for three days a week however a full time administrative post has been successfully recruited to and will commence once all the necessary checks have been completed. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 22 The operations director supports the manager, and they meet for supervision sessions on a weekly basis. External managers are also undertaking monitoring visits to the home and provide regulation 26 visit reports to CSCI. Trained staff, night staff and senior care meetings have recently been held and minutes of these were available. A residents meeting had also taken place and a relatives meeting was arranged for the following week. During the tour of the home it was observed that some bedroom doors were propped open with tables or chairs and the manager received a requirement that this practice must cease. The manager also received a requirement stating that risk assessments should be written for any resident who requests doors are held open with door guards. Staff had received fire training yesterday and training regarding COSHH was booked for the coming week. Moving and Handling training is taking place on an on going basis. A new accident and incident reporting procedure had been implemented at the home and this ensures that the manager sees all accident reports each day. All staff have been issued with a copy of the new procedure to ensure that they are fully aware of their responsibilities. The manager prepares an audit on a monthly basis. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 2 3 2 2 3 3 3 2 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X X 2 Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP2 OP3 Regulation 5(b) 14(1) Requirement Contracts of terms and conditions of residency must be issued to all residents. Pre admission assessments must be completed in full, to ensure all required information is obtained. Mental health risk assessments must be undertaken as deemed necessary for current residents. (Timescale of 09/04/05 not met) (Not assessed on this occasion) Moving and handling risk assessments must include detail of the action to be taken should a resident fall. (Timescale of 09/04/05 not met) The care planning system must be further developed to include: The actual care to be afforded to residents (including wound care). Detail of how residents’ social care needs will be met. Residents’ risk assessments Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 25 Timescale for action 30/12/05 31/01/06 3. OP4 12(1) 15/12/05 4. OP7 13(5) 15/12/05 5. OP7 15 15/12/05 must be written in more detail. Bed safety rail risk assessments must include detail of the risks involved in the use of these and consent must be obtained from the resident and/or their representative prior to the use of these. Residents or their 24/02/06 representatives must be involved in the writing of care plans and evaluations. The manager must provide 26/12/05 appropriate equipment for weighing residents who are bed bound or unable to sit on scales. 6. OP7 15 (1)(2) 12 (2)(3) 12 (1) 7. OP8 8. OP8 (The manager received this as an immediate requirement) 12 (1a)(2) Residents must be assisted to dress appropriately for the time of year, including socks or stockings as they choose. (The manager received this as an immediate requirement) Wound care afforded must reflect the wound care regime as identified in the care plan. (Previous timescale of 30/11/05 not met) All cupboards storing medication must be lockable. (Not assessed on this occasion). Medication fridge temperatures must be recorded daily. (Not assessed on this occasion) Eye drops must be dated on opening and discarded 28 days after that date. (Not assessed on this occasion) The reason that a resident does not hold the key to their DS0000024814.V272452.R01.S.doc 30/11/05 9. OP8 12(1) 10/02/06 10. OP9 13(2) 30/11/05 11. OP9 13(2) 30/11/05 12. OP9 13(2) 30/11/05 13. OP10 12(4)(a) 31/12/05 Page 26 Acocks Green Nursing Home Version 5.0 14. OP14 12 (2)(3) 15 (1) 15. OP15 17(2) bedroom must be recorded within their care plan. The manager must review the times that residents are got up in the morning and if they choose to be up by the night staff, this must be recorded on their care plan. A daily record of food provided must be kept for each resident in order to determine the nutritional content of their diet. (Not assessed on this occasion) The manager must ensure that residents and staff are fully aware of the complaints procedure and that staff report any concerns raised by residents. The adult protection policy must include the contact details of the relevant local authorities. (Not assessed on this occasion) All extractor fans are to be audited to ensure they are clean and in working order. (The manager received this as an immediate requirement) Risk assessments must be undertaken in respect of the needs for appropriate nursing, adjustable beds for those residents deemed to be in need. (Not assessed on this occasion) The cracked toilet cisterns must be repaired or replaced. The bath chair must be repaired or replaced. The manager must address the two shower rooms and ensure they are in full working order. (The manager received this as 17/02/06 15/12/05 16. OP16 22 31/01/06 17. OP18 13(6) 15/12/05 18. OP19 23(2)(b,c) 26/12/05 19. OP19 12(1) 23(2)(n) 15/12/05 20. OP21 23(2)(b,c) 03/03/06 21. OP21 23(2)(b,c, j) 26/12/05 Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 27 22. OP22 13(4a,c) 23(2c,n) 13 (4)(c) 16 (2)(j) 23. OP26 an immediate requirement) The manager must ensure that 20/01/06 raised toilet seats are adequately fitted to prevent any injury occurring. The manager must ensure that 30/11/05 all areas of the home are clean, including toilet areas. 24. OP26 (The manager received this as an immediate requirement) 13(4)(a,b) All toiletries must be removed from communal areas and returned to resident’s own rooms. (The manager received this as an immediate requirement) Action must be taken to ensure that the stale smell is eliminated in respect of one bedroom. (Previous timescale of 30/11/05 not met) The manager must address staff attitudes and provide staff training in customer care. The Registered Manager must ensure that the programme for formal staff supervision and appraisal is fully implemented. (Not assessed on this occasion) Fire doors must not be propped open with tables and chairs. (The manager received this as an immediate requirement) Risk assessments must be written for individual residents who request doors are held open with door guards. (The manager received this as an immediate requirement) 30/11/05 25. OP26 23(2)(d) 10/02/06 26. 27. OP27 OP36 12(5) 18(2) 30/03/05 21/12/05 28. OP38 23(4) 29/11/05 29. OP38 23(4) 01/12/05 30. OP38 13(4) Risk assessments in respect of the premises and staff welfare DS0000024814.V272452.R01.S.doc 15/12/05 Page 28 Acocks Green Nursing Home Version 5.0 must be reviewed and updated. (Not assessed on this occasion) 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. 3. 4. Refer to Standard OP7 OP7 OP15 OP30 Good Practice Recommendations Personal care records available should be completed each day by the care support staff. It is recommended that information that is not applicable for every resident be removed from individual care plans for ease of auditing. Menus should identify the snack time meal options on offer. It is recommended that staff training records include the content and duration of each training session, together with an indication of when updated training will be necessary. Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Acocks Green Nursing Home DS0000024814.V272452.R01.S.doc Version 5.0 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!