Inspection on 26/04/05 for Bedwardine House

This inspection was carried out on 26th April 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

Bedwardine House 27/11/06

Bedwardine House 09/01/06

Bedwardine House 29/12/04

Bedwardine House 24/05/04

Bedwardine House 08/01/04

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 BEDWARDINE HOUSE Upper Wick Lane Rushwick Worcestershire WR2 5SU Lead Inspector Nic Andrews FINAL - Unannounced 26 and 27 April 2005 9:30 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 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. BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bedwardine House Address Upper Wick Lane Rushwick Worcestershire WR2 5SU 01905 425101 01905 749723 None Mrs Victoria Lavender Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Victoria Lavender CRH 16 Dementia - over 65 Old age Physical disability - over 65 6 16 16 Category(ies) of DE(E) registration, with number OP of places PD(E) BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There were no conditions of registration other than those referred to on the previous page of this report. Date of last inspection 29 December 2004 Brief Description of the Service: Bedwardine House was a large, Georgian detached building located in a semirural position and set in extensive grounds on the outskirts of Worcester. The home had an attractive front garden and there were car parking facilities at both the front and rear of the premises. There was ramped access at the front entrance. The home enjoyed pleasant views over the surrounding countryside. The home provided personal care for a maximum of 16 older people. Six of the places were registered for older people with a dementia illness. The service users were accommodated on the ground and first floors of the building. There was a stair lift from the ground to the first floor. The home had 2 double bedrooms and 12 single bedrooms. None of the bedrooms had an en suite facility. The communal space consisted of two lounges and a dining room. Changes were being made to the communal areas following the provision of a new conservatory. BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine inspection that took place over 10 hours. A tour of the premises took place and service users’ records and staff records were inspected. Discussions were held with five of the 16 service users. The senior care assistant and newly appointed deputy manager were also interviewed. Time was also spent with the registered manager, who is also the registered provider, discussing the progress that the home had made in implementing the requirements and recommendations arising from previous inspections of the home. What the service does well: What has improved since the last inspection? A new stair lift had been installed in February 2005. A new conservatory had also been provided. A new carpet had been fitted in one of the bedrooms and in the dining room that is to become a lounge. New dining chairs had also been provided and, on the first floor, a bathroom had been refurbished and a new walk-in shower had been installed. BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 6 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. BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, and 5 Significant progress had been made to improve the home’s statement of purpose and service users’ guide. Evidence was available to show that prospective service users would be given appropriate information about the home and the service provided prior to admission. EVIDENCE: Significant efforts had been made since the previous inspection to improve the contents of the home’s statement of purpose. However, details of the actual size of the communal space i.e. dining room and lounges, (referred to in the statement of purpose as ‘social rooms’), must be included. Similarly, the number and location of the toilets, baths or assisted showers must also be included. Since the previous inspection the service users’ guide had been amended. It was pleasing to note that it contained all of the relevant information. The home had a satisfactory statement of terms and conditions (contract). It was noted that a signed copy of the contract was on the service users’ files. The home had carried out an assessment of all of the service users using a commercially produced set of forms. Separate forms for recording the service users’ medication and weight were now being maintained. In addition, dietary preferences were also being recorded on the service users’ files. The home BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 9 maintained a care plan in respect of each service user. (See the section on Health and Personal Care below 7). The assessment forms contained all of the headings referred to in Standard 3. However, the fall of one of the service users had been recorded but the date was not specified and no risk assessment was undertaken following the fall. The home had a satisfactory admission procedure. Five of the service users that were spoken to said that they visited the home prior to admission. BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9 Limited progress had been made to improve the care planning and recording. Consequently, there was insufficient information in the care plans to satisfactorily meet all of the service users’ needs. EVIDENCE: The home had produced a care plan for each of the service users and there was evidence to show that the care plans were being reviewed every month. However, the plans that were inspected did not contain specific details about how the staff should respond in certain situations e.g. when a service user became anxious. The care plans did not specify the level of assistance that a service user needed in regard to showering. One care plan stated, ‘Staff must monitor very often at night’, but did not specify how often the service user should be monitored. The care plans should include a reference to dietary preferences and also provide more space in which to record the guidance to the staff for the safe delivery of care. The home was well supported by external agencies in regard to meeting the service users’ healthcare needs. However, one service user had a red mark on the base of her spine. It had also been noted that her confusion had ‘got progressively worse’ since being discharged from hospital. The service user’s care plan did not include any reference to these issues and there was no written evidence to show that the members of staff were monitoring either of BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 11 these concerns. The home did not provide any regular or formalised exercise or physical activity. The arrangements for the administration of medication were satisfactory. Since the previous inspection a Controlled Drug register had been provided. None of the service users administered their own medication. However, three service users administered their own inhalers and two service users administered cream to themselves because of dry skin. Boots had provided training for the staff in ‘The Care of Medication’ on 28 May 2003. BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 12 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 standard(s) 15 The service users received a wholesome and balanced diet. The meals were provided in comfortable surroundings. EVIDENCE: All of the service users who were spoken to stated that the meals were ‘very good’ or ‘excellent’. The home operated a two-week menu. The record of the food provided indicated that the meals were balanced and nutritious. The cook confirmed that she was informed about any of the service users’ special dietary needs e.g. gluten-free diets, before they were admitted to the home. She also kept a list of all the service users’ personal food preferences. Alternative meals were provided to service users that did not like the main, mid-day meal that was offered. The service users were consulted daily about their choice of food for tea. The cook said that, on average, she consulted the service users once a month about the menu and made changes to it as appropriate. She also said that she baked cakes every weekday for the service users’ teatime meal. Special meals and birthday teas were also catered for. None of the current service users required any special aids to assist them with eating. None of the current service users needed their food liquidised. BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 13 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 standard(s) 16, 17 and 18. The service users had confidence in the registered manager’s willingness and ability to resolve any concerns or complaints that they might have. Service users’ civic rights were protected. Appropriate steps had been taken to protect the service users from abuse. EVIDENCE: The home had a satisfactory complaints procedure that was referred to in the home’s statement of purpose, service users’ guide and in the service users’ contract. There were no complaints against the home recorded in the complaints register. The registered manager stated that no complaints had been made against the home within the previous twelve months. No complaints about the home had been received by the CSCI within the previous twelve months. Only one of the five service users who were spoken to said that they were aware of the home’s complaints procedure. However, they all expressed their confidence in approaching the registered manager if they had any concerns or any issues that needed to be resolved. A senior member of staff confirmed that the service users that had expressed their wish to vote in the past had been taken to the local polling station to enable them to exercise this right. It was also confirmed that all of the service users had been registered to vote. Two service users were concerned that they had not received their voting cards to enable them to vote in the imminent general election. Their concern was brought to the attention of the registered manager. The home had a satisfactory adult protection policy and procedure. The registered manager confirmed that a copy of a leaflet on reporting abuse or mistreatment of vulnerable adults produced by the Worcestershire Vulnerable Adults Protection Committee had been issued to all of the staff. The registered BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 14 manager stated that no concerns or incidents of suspected or alleged abuse had been reported to her within the previous twelve months. It was also confirmed that no incidents had arisen within the home that had required a referral of any member of staff for consideration for inclusion on the Protection of Vulnerable Adults register. However, none of the staff had undertaken any training on the protection of vulnerable adults from abuse. The home had a satisfactory policy and procedure regarding the service users’ money and financial affairs. All of the service users who were spoken to during the inspection commented on the kindness of the staff and the registered manager. BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 15 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 standard(s) 19, 20, 21, 22, 23 and 24., The premises and grounds were well maintained. The service users’ bedrooms were personalised and well furnished. The communal space was comfortable and also well furnished. Improvements to the environment had been made including the provision of a new conservatory, a stair lift, carpets, dining chairs and handrails on the outside ramp at the front entrance. EVIDENCE: The premises were clean, safe and well maintained. Since the previous inspection an earlier recommendation to amend the home’s programme of routine maintenance and renewal of the fabric and decoration of the premises had been implemented. The programme now included proposed items of renewal and repair/replacement and the anticipated dates of completion. The grounds were tidy, safe and attractive. A new conservatory had recently been provided at the rear of the premises. This was being used as a dining room. The registered manager must provide written evidence to show that the conservatory complies with all of the required Regulations and standards. It was intended that the room that was formerly used as a dining room would become a lounge. It was also intended BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 16 that one of the existing lounges would be converted into a single bedroom and the number of service users for whom the home was registered increased by one person. A satisfactory amount of communal i.e. shared, space was provided. Lighting was domestic in character and the furnishings were comfortable. The service users had access to the gardens. The home had a ‘no smoking’ policy. None of the service users smoked. Staff who smoked are allowed to smoke outside the premises. None of the bedrooms had an en suite facility. However, the home met the Standard for home’s registered prior to April 2002 in regard to the number of toilets and bathrooms. Since the previous inspection one of the baths had been replaced with a shower. It was also intended to refurbish a bathroom on the first floor and to replace the existing bath and shower with a bath and a hoist. There were three separate toilets and a shower with a toilet on the ground floor and a separate toilet, a bath with a toilet and a shower with a toilet on the first floor. A separate toilet was provided for the staff on the first floor. There were handrails in the corridors and grab rails in the bathrooms and toilets to enable service users with mobility problems to move around the home more safely. However, the premises had not yet been assessed by a qualified occupational therapist. Adequate storage facilities were provided. All of the rooms were installed with a call alarm. The registered manager stated that it was intended to provide a passenger lift in the future when the home was extended. A ramp must be installed at the rear of the premises leading from both the new conservatory and the rear door. Plans had been made to install a ramp leading from the conservatory in the near future. The registered manager said that a ramp leading from the rear door would be provided in the longer term. In the meantime, handrails must be provided on the walls either side of the rear entrance. It was pleasing to note that hand rails had been fitted to the sides of the ramp at the front entrance. The service users had adequate personal space. The home provided twelve single bedrooms and two shared rooms. The size of the bedrooms met the Standards in regard to homes that were registered prior to April 2002. One bedroom had only one comfortable chair. The registered manager said that she would provide a second comfortable chair for the service user. Apart from this one exception, all of the service users’ bedrooms contained all of the items referred to in the Standard. BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 The staff recruitment procedures had improved since the previous inspection. However, there was scope for further improvement by ensuring that appropriate information was obtained regarding the health of both the current and prospective staff. EVIDENCE: Since the previous inspection a deputy manager had been appointed. The details on the staff rota had also been improved. The home had an equal opportunities policy. However, it had not been necessary to recruit any new staff since the previous inspection. The home’s application form had been amended and improved for use in any future staff recruitment procedure. A form should be devised to enable prospective staff to give their permission for the registered manager to obtain a medical reference from the applicants’ GP, if necessary, in appropriate circumstances. All the staff should be asked to complete the home’s medical questionnaire. All the staff had undertaken a check with the Criminal Records Bureau. All the staff had been issued with a copy of the code of conduct and practice set by the General social Care Council. The registered manager confirmed that she would explain the code of conduct and practice to a member of staff for whom English was not their first language. The discussion should be recorded in the supervision notes. It was confirmed that all the staff had been issued with a contract. It was noted that three previous requirements regarding individual training and development assessments and profiles, staff core training and staff induction and foundation training had not been fully implemented. The information that was held by the home regarding training should be brought together into individual files and the future training needs in respect of each member of staff BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 18 and how these should be met clearly identified. It was pleasing to note that arrangements had been made to provide training for the staff in core areas. However, the training had not yet been undertaken. One new member of staff had not undertaken induction and foundation training to National Training Organisation specification. BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 The management of the home was satisfactory overall but some areas of practice needed to be improved. EVIDENCE: It was confirmed that individual supervision meetings and staff meetings were held. The meetings should be more frequent. For example, only three meetings with the service users had been held during the previous ten months. However, it was pleasing to note that questionnaires had been used to obtain the views of the service users. One of the service users had given a talk to the other residents about living in Worcester. However, there was very little evidence to show that management planning and practice encourage innovation, creativity and development. The registered manager expressed her commitment to equal opportunities. It was pleasing to note that the registered manager and two other senior members of staff had undertaken training provided by Age Concern on Abuse Awareness on 4 March 2005. It was also pleasing to note that the home had responded to a previous requirement and had introduced an Annual BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 20 Development Plan. However, the Plan only covered the period from January to April 2005. The Plan must cover the whole year and give a clear indication of the aims and outcomes for the service users in respect of all of the items referred to in the Plan. The home had introduced service user satisfaction questionnaires and visitors’ questionnaires in November 2004. Service user questionnaires had also been issued between 19 and 26 February 2005. The responses had been analysed and the results recorded in the service users’ guide. However, a full, formal quality assurance system had not been implemented. The financial statements for the home for the year ended 31 March 2004 were available for inspection. However, the home did not have a business and financial plan. It was pleasing to note that the service users’ money held by the home was kept in separate pouches in a lockable box. Access to the money was restricted to the registered manager and two senior staff. The frequency at which supervision meetings were being held had increased. However, insufficient time had elapsed to enable a judgement to be made regarding whether the previous requirement on this issue had been implemented. The supervision forms contained minimal information. This aspect of recording needed to be improved. The records relating to staff were satisfactory except for one file that did not contain a photograph. It was pleasing to note that the staff records were now being kept in a lockable box. Access to the records was restricted to the registered manager. BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 2 3 3 x x STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 x 2 x x x x x x BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 22 Yes 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 1 Regulation 4 Requirement The statement of purpose must be amended so that it includes the size of all the communal rooms i.e. shared space, and the number and location of all the toilets, baths and assisted showers. (Previous timescale of 28 February 2005 not met). A risk assessment must be carried out and recorded in respect of each servic user in order to identify and, so far as possible, eliminate any risk of falls. All service user plans must contain clear, specific and detailed guidance to staff for the safe delivery of care. (Previous timescale of 31 March 2005 not met). The homes care plan must include a specific reference to dietary preferences in accordance with the requirements of Regulation 14 and Standards 3 and 7. (Previous timescale of 31 March 2005 not met). The service users physical and psychological health must be monitored, recorded in their care Timescale for action 31 May 2005 2. 3 13 31 May 2005 3. 7 15 31 May 2005 4. 7 15 31 May 2005 5. 8 12, 13 30 June 2005 Page 23 BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 6. 8 12, 13 7. 8. 18 20 13,18 13,23 9. 20 13,23 10. 20 23 11. 20 23 12. 20 13,23 13. 22 23 plan and preventive and restorative care provided.. Opportunities must be provided for service users to receive appropriate exercise and physical activity. All the staff must undertake training in the protection of vulnerable adults from abuse. Written evidence must be provided to show that the new conservatory meets with the approval of the Fire Safety Officer. The portable heater must be removed from the conservatory and fixed heaters/radiators and an air conditioning system provided that meet with the approval of the Fire Safety Officer. A suitable ramp with fixed handrails leading from the door of the conservatory to the rear patio must be provided. Written confirmation must be provided to show that the conservatory meets all of the Councils Building Control Regulations appropriate to the conservatorys proposed use as a dining room. An amended copy of the homes fire risk assessment that takes account of the provision of the conservatory and evidence to show that the revised fire risk assessment meets with the approval of the Fire Safety officer must be provided. Egress from the home to the outdoor space must be made safe for the service users in wheelchairs and those with mobility problems by the provision of a ramp at the rear of the premises in accordance with Regulation 23 and Standard 22. 30 June 2005 31 July 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 September 2005 BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 24 14. 22 23 15. 30 18 16. 30 12,18 17. 30 12,18 18. 33 24 19. 33 19 20. 36 18 (Previous timescale of 30 June 2005 extended). Suitable handrails must be fitted to the outside wall on either side of the door at the rear of the premises for the safety of the service users. All staff must have individual training and development assessments and profiles. (Previous timescale of 28 February 2005 not met). All staff must receive up-to-date training in moving and handling, food hygiene, health and safety, infection control and fire safety. (Previous timescale of 31 March 2005 not met). All new members of staff must receive induction and foundation training to National Training Organisation specification within 6 weeks and 6 months of appointment to their posts, respectively. (Previous timescale of 31 March 2005 not met). An annual development plan for the home, based on a systematic cycle of planning - action review, reflecting aims and outcomes for service users, must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 31 March 2005 not met). A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 31 March 2005 not met). Care staff must receive formal supervision at least six times a year that includes all aspects of practice, philosophy of care in the home and career 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 25 21. 37 17 development needs. The supervision forms must include clear, relevant details of the issues that are discussed. (Previous timescale of 31 March 2005 extended). All of the staff files must include a recent photograph of the respective staff member. 30 June 2005 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. Refer to Standard 22 Good Practice Recommendations The advice of a qualified occupational therapist should be sought in order to ensure that the home provides all of the recommended disability equipment and environmental adaptations to meet the needs of the service users. All prospective staff should sign a form giving their permission for the registered manager to obtain a medical reference from their GP in appropriate circumstances. All of the staff should complete the homes medical questionnaire. Staff meetings should be held at least every three months. Evidence should be provided to show that management planning and practice encourage innovation, creativity and development A business and financial plan for the establishment should be drawn up, made open to inspection and reviewed annually. 2. 3. 4. 5. 6. 7. 29 29 32 32 34 BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 Page 26 Commission for Social Care Inspection John Comyn Drive Droitwich Road Worcester WR3 7NW 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 BEDWARDINE HOUSE E52 S18631 Bedwardine House V223471 260405.doc Version 1.30 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!