Inspection on 22/05/06 for Barkat

This inspection was carried out on 22nd May 2006.

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

Barkat 01/05/08

Barkat 03/05/07

Barkat 11/01/06

Barkat 05/07/05

Barkat 19/01/05

Barkat 06/02/04

Barkat 19/08/03

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 Barkat 254 Alcester Road Moseley Birmingham West Midlands B13 8EY Lead Inspector Jill Brown Unannounced Inspection 22nd May 2006 09:00 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 Barkat DS0000016738.V289436.R01.S.doc Version 5.1 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. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Barkat Address 254 Alcester Road Moseley Birmingham West Midlands B13 8EY 0121 449 0584 0121 449 2726 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) Ms Seemia Butt Ms Shahnaz Butt Ms Seemia Butt Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the home can accommodate up to three people under 65 years of age for reasons of mental disorder. All of the senior staff undertake a course in the management of challenging behaviour by January 2005. 11th January 2006 Date of last inspection Brief Description of the Service: Barkat House is a large detached property situated on the main Alcester Road in Moseley. It is within easy walking distance of the main shopping area of Moseley where shops, restaurants, public houses and churches can be found and a larger shopping area can be found by walking to Kings Heath. The home enjoys easy access to public transport routes leading to the city centre and beyond. Barkat House offers accommodation to currently 25 older people in single rooms on the ground and first floor. There is a passenger lift between the ground and first floor. Communal areas are located on the ground floor. There is a large lounge to the front of the house, a smaller lounge to the rear. Residents that smoke use the small lounge. The home has a separate dining room. The home has communal toilets and either an assisted bathing or a shower facility based on both floors. The ground floor also houses the kitchen, office, laundry and large storage area. The home has a dedicated garden for the use of service users. The home has a small amount of parking at the front of the building. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over about 7 hours on a day in May. During the inspection care records for three residents and three staff records were looked at. Medication records were sampled, accident records looked at and maintenance and inspection records of services such as fire, food, electric and gas supplies and lifting equipment. A number of policies and procedures were sampled. The inspector received 10 comment cards from residents and 11 from relatives. During the inspection the inspector spoke to 6 residents and 2 staff above the manager and the 2 deputy managers. Two health care professionals were spoken to. What the service does well: The home collects good information about residents’ lives prior to their admission into the home. This information can help in ensuring appropriate care especially for residents with communication difficulties. The home has a staff group that reflects the ethnic origins of a number of the residents. They are able to ensure that residents that are admitted have a member of staff that can speak their first language. The home ensures that residents have the opportunity to follow their religious belief if they wish. Arrangements are also made to ensure that appropriate food is available. Residents are assessed before being admitted to the home and the residents accepted are appropriate to the home’s category of registration. Residents and relatives described staff as ‘kind’ and it was said treated residents with dignity. Staff approached residents that were having a difficult day calmly and sensitively. Residents’ health and personal care needs were met and it was possible to show where concerns were raised that action had been taken by the home. Residents had a choice of rising ties and going to bed and were allowed freedom to go out where this was safe and when possible staff accompanied residents that weren’t safe to go out alone. Visitors said that they were always felt welcome at the home. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 6 Staffing levels were good with appropriate numbers of care and ancillary staff to meet the needs of the residents in the home. The home understands the process of adult protection and consults appropriately with other agencies to protect residents. What has improved since the last inspection? What they could do better: The home did not collect enough information on residents’ moving and handling, nutrition, foot and oral care needs. This meant the home did not plan appropriately for these needs. The home did not show that residents always visited the home prior to their admission and did not record how the person’s needs were to be met on admission. Care plans were not reviewed monthly to ensure that the information on the way care was to be delivered remained correct. The home needed to ensure that unplanned weight gain and falls resulted in appropriate planning if this was a risk to a resident’s health. The home did not provide a choice of meals on their menus and did not show that they encouraged a healthy eating plan. Activities were not arranged to meet the needs of individual residents. A number of residents that were unable to entertain themselves did not have activities or time with an individual member of staff recorded. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 7 Whilst staff files were improving a number of requirements were made about ensuring that staff had the training needed and the home being able to show that this was being done. The home had failed to ensure that a staff member’s record of leave to remain in the country was updated in their file. The home could not show that they had monitored their performance across all areas of the care. So this allowed for example care plans to remain inconsistently completed and for there to be no link made between food provided and residents’ weights. The home did not have a quality assessment system that it could use to enable this process. The home had been short of management time to further this and this was shown by the lack of planned recorded supervision of staff and the lack of progress on a number of previous requirements. 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. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 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 Barkat DS0000016738.V289436.R01.S.doc Version 5.1 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, 4, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes arrangements for assessing needs and admission of residents needed improvement to ensure that residents are appropriately placed at the home. The home makes good arrangements for residents’ cultural and religious needs to be met. EVIDENCE: The home charges £332 .00 per week for their rooms. The home has made four bedrooms en suite and added two new en suite bedrooms. En suite bedrooms when they become available may be charged more for. All the residents placed are subject to social services contract with the home and the resident. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 10 The home collects adequate information about residents’ needs but a number of details need to be added to ensure that good instructions for staff can be written. These missing details include assessments of nutrition, moving and handling and skin risk and information on teeth and foot care. The home collects good information on resident’s social habits such as going out, smoking and drinking. A number of residents had life history information and this work could usefully be carried out with residents to assist the planning of care. The home has a number of residents from the black and minority ethnic communities and has a number of staff from these communities that are able to converse in appropriate languages. The home makes arrangements for residents to have their religious needs met. The home has only admitted residents that it is able to provide care for. Staff demonstrated a calm and caring attitude when a resident had been drinking and this was commended. It was clear from records that residents were assessed prior being admitted but it was not always clear whether residents had a visit to the home prior to their admission. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 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, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for care planning were variable and this could mean that the care given to residents is inconsistent. Residents’ health, personal care and needs were substantially met in a kind and caring way. Attention to detail would ensure that arrangements were good and this would improve residents’ care. EVIDENCE: Care plans remained better than previously but they still had gaps and still varied in quality. Partly this was due to not collecting the information initially for example on foot and oral care and partly not recognising the need to structure the care plan in a more individual way. This was important for residents that were beginning to develop dementia. One resident’s care plan had clear instructions about the risk associated with smoking another resident’s care plan didn’t. The home also needed to give information on triggers for identifying when a resident was becoming depressed where this was an issue raised in their assessment. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 12 One resident needed a night care plan. One resident had care plans for a range of medical conditions, mobility, communication, personal hygiene and religious needs. Care plans had not been reviewed monthly to check if they were still appropriate. The home followed up medical concerns and where hospital appointments were needed a clear track could be found to the home’s diary to ensure that residents attended. Residents’ personal hygiene needs were met as much as individual residents would consent. Residents were approached at differing times to gain agreement for their needs to be met. Records looked at for new residents suggested that residents became more willingly to have personal care the longer they stayed at the home. A social care and health worker said that the home worked well with residents that had behaviour not acceptable in other homes ‘they were able to sustain a relationship’ with these residents. He said that the home’s ‘interventions were flexible and on an individual basis.’ Residents’ weights were recorded on a monthly basis where compliant. Residents’ weights were mostly increasing and losses were not of concern. A number of residents needed action taking to lessen weight and this needs to be part of the nutritional screening and healthy alternatives put on the menu. Residents at the home do not have an undue amount of accidents or falls. Medication administration and storage was generally good. A number of residents had yet to have a photograph put on the Medication Administration Record (MAR) and this helps to ensure that medication is given to the right person. There was a concern about the performance about one member of staff and the administration of one drug and this issue must be addressed. Drugs in the monitored dosage system could not be checked, as this was the first day of the cycle. There have been some communication issues about drugs with the GP practice and these are being worked on at present. The medication room window had no covering and this is not good for security. The staff have to ensure on a rota basis that the medication room is clean and tidy. It was clean and tidy on the day of the inspection and this is commended. The chairs in the medication room needed replacement especially if it is used for consultations. The home did not have a reference book to confirm any queries on medication. Comment cards from residents and their relatives said ‘Thanks for professional and caring way of staff,’ ‘Staff are friendly’ and ‘everyone is treated with dignity.’ One resident was being shaved in the main lounge during the inspection and all attention to personal care needs should take place in private. A health professional stated that residents were treated kindly and appear happy at the home. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 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): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for activities and meals did not always show that they responded to the individual needs and choices of the residents. The arrangements for visitors and choices in daily living were good and this enhances resident’s lives. EVIDENCE: Individual activity plans were not available for residents that have difficulty in joining group activities and didn’t reflect the resident’s interests. A number of residents spoken to made it clear that they prefer just to watch the television however others were not able to express this choice and may benefit from other ways of engaging interests such as magazines of previous interests, newspapers in an appropriate language, hand massages, foot spas, football nights and so on. The care plans need to show what provokes interest from the resident. One comment card from a relative requested that residents should be taken out. A number of residents go out independently or with assistance, a number attend centres external to the home. The improving weather should permit more residents to take advantage of going or being taken out. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 14 Visitors comment cards said that they were made welcome at the home. There were no undue restrictions to visitors to the home. During the inspection it was clear that residents were able to get up and retire when they wanted. Breakfast appeared to a moveable event with lunch and tea at set times. Residents were able to access their bedrooms at any time. There were no undue restrictions of movement although a number of residents for safety reasons needed to be accompanied outside of the home. The menus provided did not show the Halal option that was available and did not show a choice of food at lunch. On the day of the inspection whilst special needs were met there was no choice of food. It was clear from residents’ weights that the residents had enough to eat however the menu must be looked at to ensure that enough nutritional content such as fruit and vegetables are given through out the day. Residents that needed assistance and encouragement to eat were given this assistance. One resident said that he thought that the food had got better since he raised the issue with the manager. Other residents thought that either the food was good or that the choice was limited. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission received a complaint about the control of infections; the residents’ personal hygiene needs not being met and residents that were unable being made to walk to appointments. The Commission found that the regulations were met in respect of these concerns. A complaint was noted in the daily records but not reported in the home’s complaint log. Although there was no evidence to support the complaint it needed to be logged in case there were further issues arising from it. Two other complaints were logged in regard to missing items and these items were found in the home, which would suggest this is the homes normal practice. The home does not record informal comments and this means they miss information that may inform their quality assurance processes. The home has a good adult protection policy and is aware of how to implement this policy. An adult protection issue between two residents had been handled appropriately. A number of the staff have still to undertake training on adult protection. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not developed a robust refurbishment and management of repairs process; this prevents the home providing a fully safe and comfortable environment for residents. EVIDENCE: The home has a population of residents whose needs are such they are heavy on decoration and furnishings. However a number of bedrooms require refurbishment, odour control and repair. Some health and safety issues need to be addressed to provide a safe and comfortable place for residents. For example the room containing the commode disinfector requires a numbered lock, a resident that smokes needs a metal bin his room which should contain a little water to prevent fire, a radiator cover needed fixing, a number of ceilings needed replacement tiles to look reasonable and the downstairs toilet by the smoke room needed upgrading. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 17 The home needed to invest in some more bed linen and pillows to ensure that they have enough of reasonable quality. The checking of the safety of hot water temperatures had not been recorded since February and these must be sampled throughout the home monthly. This ensures the risk that the risk to residents of being scalding is minimised. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels were good and there was an improvement in courses that were on offer to staff and this protects residents. However the home had to improve its records and checking on the recruitment of staff and records of the staff teams attendance on course to show that residents have the benefit of a safe well trained staff group. EVIDENCE: The home had an appropriate number of staff on duty at the time of the inspection. Rotas showed that 3 care staff are on duty with a manager in the morning and after noon shift through out the week this rises to 4 at the weekend including a senior care. The home has two night staff on duty. One of the deputy managers supplies additional input two mornings a week. The homes information shows that 38 of staff hold NVQ2 and this needs improvement to meet the requirement of 50 . Not all staff had photos on their staff files. All staff had completed an application form; there was no evidence of interview questions and responses. All but one staff had an appropriate Criminal Records Bureau check the other was in process. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 19 The home must ensure they have systems in place to follow up dates where the residents leave to remain in the country is time limited and in one case ensure that a copy of the persons leave to remain is sent to the Commission. The home did not have a matrix of staff attendance at training courses nor their achievement of mandatory training and this meant that they could not show that all staff had the appropriate training. However the staff files sampled showed an increased level of mandatory training and the home had evidence of booked training on dementia and infection control. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The level and training of the management needs improving to ensure improvements in this area. Residents, staff views and checks on the homes performance across all of the service the home provides needs to inform the future development of the home. This lack means that problems cannot be identified and sorted out quick enough to prevent residents’ being at risk or unhappy with the service. The home has responded to previous requirements made to improve the health and safety aspects of the home. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 21 EVIDENCE: The manager of the home has to complete an NVQ level 4 in care and a Registered Managers Award, as she has been the manager of the home for a number of years prior to these requirements being made. The home had a requirement to employ another deputy and this has been partially achieved by an existing member of staff working part time as a deputy and she is qualified to NVQIII in care. The home hopes to employ some admin support that would assist in relieving the owner to undertake other required tasks. The manager has staff meetings but these could be more regular. Residents meetings have not been successful in the home and the manager must look at other ways of getting residents views possibly by using the residents’ key workers. The home does not have a quality assurance system. This means that the home is not identifying poor practice, and does not have a clear way of deciding on improvements it needs to make. The management of residents’ money was appropriate and the amount of money held for residents tallied with the paper record. A large number of the residents smoke and the home uses different methods to allow residents access to their money according to the residents ability to manage. The formal supervision of staff had not been undertaken recently and the home was unlikely to meet the required frequency of six supervisions for all care staff. The management of the home was not at the level to ensure that these processes are imbedded into the system. The home has the appropriate gas, electric service maintenance and inspection contracts. Lifting equipment is routinely checked. The home has responded to the requirements made the last Fire Inspection and drills and training in fire safety have taken place. The home had a number of requirements about the kitchen; an inspection by the Food Safety department in April showed these areas were no longer of concern. A small number of requirements were made by the Food Safety Department and the inspector was advised that the Food Risk assessment remained outstanding. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 2 3 2 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 X X 2 2 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 X 3 1 X 2 Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 23 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. Standard OP3 Regulation 14(1)(a) Requirement The home must ensure that all areas of the assessment outlined in standard 3 are commented upon in each resident’s assessment including foot, skin, nutrition and moving and handling care. (This remained outstanding from 31/01/06). The home must keep a record of a potential resident’s visit to the home and the outcome of that visit. All residents must have risk assessments to include skin viability, nutrition, mobility and handling (plus smoking and behaviour where necessary). Ways to minimise these risks must be documented in the care plan. These plans must be reviewed monthly. Residents that need to lose weight for health reasons must have a plan and healthy options for meals and snacks to achieve this. DS0000016738.V289436.R01.S.doc Timescale for action 01/06/06 2 OP5 14(1)(d) 01/06/06 3 OP7 15 13(4)(c) 01/06/06 4 OP8 12(1)(a) 30/06/06 Barkat Version 5.1 Page 24 5 OP9 13(2) Sch3 (2) All residents in the home must 30/06/06 have a photograph on record and it is recommended that this is kept with the Medication Administration Record (MAR) The Manager must audit the administration of medication and where procedure is not followed take action. The window covering to the medication room must be replaced. The home must obtain a BNF to ensure they are conversant with any changes in medication. The home must develop an activities programme for service users of the home and keep a record. (This requirement remains outstanding 31/05/05 and 31/03/06). Records must be kept of individual time spent with residents unable to join activities. (This requirement remained outstanding since 31/08/05 and 31/03/06). The home must ensure that there are least two clear choices of food at meal times. Food must be available to ensure that residents have a nutritious diet and where needed are enabled to lose weight. The Registered Manager must ensure that staff have the relevant training in adult protection. (This requirement remains outstanding since 30/04/05 and 31/05/06). 6 OP12 16(2)(n) 30/06/06 7 OP12 16(2)(n) 30/06/06 8 OP15 12(1)(a), (3) 30/06/06 9. OP18 13(6) 30/08/06 Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 25 10 OP19 23(2)(b) The Registered Manager must 30/06/06 ensure that water damage evident in some areas is repaired (This requirement remains outstanding 30/04/05 and 30/04/06.) The home must ensure that the building is audited for repairs, refurbishment, décor and linen and a programme of improvement must be sent to the Commission by 19.6.06 (A number of requirements in respect of this requirement remained outstanding from previous inspections). All toilets must have the provision of two grab rails or a toilet frame. This requirement remains outstanding 05/09/05 and 28/02/06. The ground floor toilet by the smoke room requires refurbishment. The home must routinely take water temperatures of taps the residents have access to and keep a record. The room housing the commode disinfector must have a numbered lock to prevent injury to residents. 19/06/06 11 OP19 23(2)(b) (d) 12. OP21 23(2)(b) (d)(n) 30/06/06 13 OP25 13(4)(c) 30/06/06 14 OP26 13(4)(c) 13(3) 30/06/06 15. OP28 18(1)(c) (i) Odour control measures must be put into place a remedial action taken on rooms that are found to have an odour on the home’s audit. The home must have a plan to 30/06/06 achieve 50 qualified NVQ2 staff by December 2005. (This remained outstanding since 31/08/05 subsequent date has not expired.) DS0000016738.V289436.R01.S.doc Version 5.1 Page 26 Barkat 16 17 OP29 OP29 18. OP30 An appropriate photograph must be on the staff file. Sch 2(7) The home must ensure that they have a mechanism to follow up the expiry dates on leave to remain in the country and must send to the Commission a copy of a specified member of staff leave to remain by Sch (2)(4) The Registered Manager must 18(1)(c) ensure that staff files: Have copies of the member of staffs relevant qualifications to demonstrate that staff have met the National Training Organisations targets. (This requirement remains outstanding since 01/07/04 and 28/02/06). A staff training matrix of courses attended must be sent to the Commission by 15/07/06. The registered manager must undertake the NVQ4 in care and the Registered Managers Award. (The timescale for this has not yet expired.) The home must find ways to gain residents views of the service they offer as part of the home’s continual improvement. The home must set up a method of quality assurance and this must be reflected in the homes business plan. (This requirement remains outstanding since 01/07/04 and 31/03/06). Staff must receive regular routine 1 to 1 supervision. A rota of planned supervisions must be sent to the Commission by 30/06/06. (This remains outstanding since 28/02/06) All staff must receive supervision by 30/06/06 DS0000016738.V289436.R01.S.doc Sch 2(2) 15/07/06 15/07/06 15/07/06 19. OP31 9 31/12/06 20 OP32 12(3) 30/06/06 21 OP33 24 31/07/06 22. OP36 18(2) 30/06/06 Barkat Version 5.1 Page 27 23. OP38 18(1)(a) 24 OP38 13(4)(c) 13(3) To ensure the safety of residents the management of the home must be strengthened and a full time deputy, with care experience and qualifications, must be in place as a permanent addition. (This requirement was partially met at the time of the inspection further admin support is planned.) The home must ensure that a food risk assessment is completed. 31/07/06 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP16 Good Practice Recommendations It is recommended that the chairs in the medication room be replaced to provide an appropriate place for consultations. It is recommended that the home collect any grumbles made by residents as a way of informing a quality assurance process. Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 28 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 Barkat DS0000016738.V289436.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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