Inspection on 04/10/05 for Berwood Court Care Home

This inspection was carried out on 4th October 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

Berwood Court Care Home 06/06/07

Berwood Court Care Home 04/07/06

Berwood Court Care Home 16/11/04

Berwood Court Care Home 20/05/04

Berwood Court Care Home 11/11/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Berwood Court Cadbury Drive Castle Vale Birmingham B35 7EM Lead Inspector Amanda Lyndon Announced 4 October 2005 th 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. Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Berwood Court Address Cadbury Drive Castle Vale Birmingham B35 7EM 0121 749 7887 0121 749 7997 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) Dukeries Healthcare Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39)Dementia- over 65 years of age (39) of places Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home can accommodate thirty nine older people who are in need of personal care or nursing care for reasons of old age or dementia. 2. Minimum number of nursing staff and care staff appropriate to meet the needs of the service users will be provided as agreed with the Commission. 3. The Registered Manager achieves the Registered Managers Award or equivalent to NVQ Level 4 in management by the end of 2005. Date of last inspection 16th May 2005 Brief Description of the Service: Berwood Court is a 39 bedded purpose built nursing and residential home situated in a residential area of Castle Vale in Birmingham. The care home is located on the first floor of the building and is split into two units, residential and nursing care. All bedrooms are for single occupancy with an en suite facility. There are communual lounge and dining rooms available for residents. Assisted bathing facilities are provided in convenient locations within easy reach of residents bedrooms. A rehabilitation unit, managed by the Primary Care Trust is located on the ground floor and this is not inspected by The Commission for Social Care Inspection. Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report reflects the findings of two inspections visits, the first being as part of an unannounced complaint investigation following the receipt of two complaints about the standard of service provided and the second being the announced inspection when there were thirty eight residents living there. A number of issues raised as a result of the complaints received were found to be upheld, however it was pleasing that remedial action had been undertaken to address these by the time of the second visit. Information was gathered from speaking with residents, visitors and staff, observing staff perform their duties and examining care, medication and health and safety records. A tour of the premises was also undertaken. The Commission did not receive any completed comment cards in respect of the service provided at Berwood Court This is the second inspection of this service in the 2005/2006 inspection year and linked to the Commission’s focus on outcomes for residents and proportionate inspection, we would recommend that you read this report in conjunction with the last inspection report of this service on 16 May 2005. What the service does well: What has improved since the last inspection? Care plans now included information about the preferred daily routines of residents and this ensures that their individuality is maintained and respected Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 Page 6 and residents now have regular access to a visiting dentist. Further development of the care plans is needed to ensure they are regularly reviewed. Residents and relatives are now invited to group meetings to discuss the service provided at Berwood Court There are generally robust systems in place for staff recruitment and this ensures that residents’ safety and welfare are protected 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. Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 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 Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 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 & 4 The assessment and admission processes are comprehensive which ensures that the prospective resident has all relevant information about Berwood Court and are aware that their individual care needs can be met. The Home can meet the needs of the majority of residents living there. EVIDENCE: The Organisation had produced a comprehensive statement of purpose, however this did not reflect the current service provided at Berwood Court and must be amended. Good work had been undertaken in respect of the service user guide since the previous inspection, however this now required amending to reflect current practice and must be accessible to each resident. Pre admission assessments are undertaken for all prospective residents using a comprehensive pre admission assessment document and residents are issued with comprehensive contracts of terms and conditions of residency. Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 Page 9 Care reviews were undertaken, however, the appropriate authorities were not always informed of residents changing needs to ensure that their care needs could still be met at the Home. Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 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, 9 & 10 Residents’ general health and personal care needs are generally well met, however the monitoring of and documentation in respect of this was inadequate at times, putting residents at risk. The system for the management of medication was not always safe and this may pose a risk to residents’ safety. Residents are generally cared for in a respectful manner by staff working at the Home and this ensures that their dignity and self esteem are maintained. EVIDENCE: Comprehensive assessments of residents’ holistic needs are undertaken on admission and care plans are derived from this information. Care plans for residents receiving nursing care were recorded in good detail, identified the support required from the care staff for each particular care need, included the preferences of the individual residents in respect of their daily lives and were reviewed each month. Comprehensive wound care plans were in place, however these were not always updated to reflect the current wound dressing regimes and social histories and communications with residents’ families were not always completed. Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 Page 11 Personal risk assessments for residents had been undertaken as required. Consent had been obtained in respect of the use of bed safety rails, however these did not include detail of the risks involved in the use of these There were inconsistencies in the recording of pressure sore risk assessments for people receiving residential care and it is recommended that further training is provided for staff in this area. In addition to this, not all residents receiving residential care were weighed regularly despite new weighing scales having been purchased. A number of care plans in respect of the activities of daily living for people receiving residential care had not been completed and this would suggest that further staff training is also required in this area. The Commission received a complaint that residents’ personal hygiene care needs were not met and despite residents appearing to be well supported in this area during the inspections, there were inconsistencies in respect of the care plan and the actual care afforded as recorded on the personal care records and key worker diaries, therefore it was difficult to evidence what care had actually been given on some occasions. Other daily reports were, however recorded in good detail. Residents had access to Health and Social Care Professionals including their General Practitioner, Optician, Dentist, Chiropodist, Social Worker and Specialist Nurses, and a written record of these visits was available. The Commission received a complaint that an inadequate number of drinks were served to residents and this was found to be unresolved, however fluid and dietary intake records as deemed to be necessary had been implemented at the time of the second inspection. A medication audit had been undertaken and multidisciplinary advice had been sought in respect of the covert administration of medication prior to the second inspection visit, however improvements were required in respect of the management of medication at the Home. • The Commission received a complaint that a prescribed cream is not administered correctly and this was found to be upheld as prescription labels did not always detail comprehensive dosage instructions • • • • The actual dosages administered in respect of variable dosages were not recorded on medication administration charts Medication was not signed for immediately following administration Reasons for non administration of medication were not recorded on medication administration charts There was less than three hours between the morning and lunch time medication rounds and this is considered to be an unsafe practice. E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 Page 12 Berwood Court • The residential medication trolley was unlocked and unsupervised in the corridor. Bedroom doors were fitted with appropriate privacy locks and residents had the option of holding the key for these. Prior to the inspection, The Commission received a complaint that staff did not always communicate with residents in an appropriate manner and during the first inspection this was found to be the case on one occasion. This was brought to the attention of the Care Manager who has now addressed this issue. Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 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 standard(s) 12, 13 & 15 The current activities on offer do not meet the needs or expectations of residents living at the Home. Residents maintain contact with their families and friends with support from the staff. Residents receive a wholesome and varied diet which meets any special dietary needs. EVIDENCE: An activities co ordinator is due to commence employment at the Home in the near future and a variety of activities are planned. In the interim there had been few activities on offer to the residents, including manicures, aromatherapy and an entertainer. A hairdresser visits once a week and Holy Communion is available. There were no activities on offer specific to the needs of residents with dementia. One resident said “ There are no activities here now, there is no entertainment”. Another resident said “ I really enjoy watching my favourite television programmes”. There is an open visiting policy. One visitor said “ They treat me very well here, I always have a cup of tea when I visit”. The choice of main meals were wholesome and well presented and portions of pureed diet were served separately in keeping with good practice. Special diets were catered for and there were appropriate adapted feeding aids and utensils available. Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 Page 14 Staff were assisting residents in a respectful manner during their meals, food was cut up into manageable portion sizes and appropriate protective aprons to protect residents’ clothing were worn. The dining tables were laid attractively and cold drinks were served. Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 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 standard(s) 16 & 18 Complaints are investigated in an appropriate and timely manner to the satisfaction of the complainant. Overall, the Home has good systems in place to protect residents from abuse, however further staff training in this area is required to afford full protection for the residents. EVIDENCE: Part of this inspection was in response to two complaints received by the Commission regarding the delivery of residents’ care, health, safety and welfare, and a number of these were found to be upheld. In addition to this the complaints log contained a comprehensive record of complaints received by the Home in relation to care delivery, fees payable and health and safety issues. There was evidence of thorough investigations into these issues raised being undertaken by the Organisation in an appropriate and timely manner to the satisfaction of the complainants. One resident said “ I would talk to the Manager if I wasn’t happy about anything” The Commission had received a complaint that the Home’s staff do not respect the personal belongings of residents and the outcome of this was unresolved. One resident said “ I have got a lot of ornaments in my room and the staff look after them when they are in my room” The Organisation had produced a comprehensive policy in respect of the protection of vulnerable adults , however, despite Local Authority guidelines Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 Page 16 being available, the policy did not clearly state the Local Authority’s lead role regarding adult protection and the contact details of relevant authorities were not available. Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 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 standard(s) 19, 22, 24, 25 & 26 Residents are provided with a homely, comfortable and well maintained environment to live in and aids, adaptations and equipment provided ensure that residents’ needs are met. The internal temperature within the Home is unacceptable and the high temperature may be detrimental to the health of both residents and staff. A number of working practices do not follow good infection control procedures and these pose a risk to residents’, staff and visitors’ health. EVIDENCE: The internal environment of the Home was homely in style, comfortable and well maintained. Furniture, floor coverings and fittings were of a good standard. There had been no progress since the previous inspection in respect of the external grounds facilities for residents living at the Home, however there was ample space for all residents residing at Berwood Court to enjoy the gardens. Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 Page 18 Appropriate pressure relieving equipment was available to meet residents’ needs and there were a number of adjustable nursing type beds. Bedrooms contained residents’ personal items and there was a nurse call facility and lockable storage facility in each bedroom. The internal temperature of the Home was found to be uncomfortably hot on the day of the inspection with random temperatures ranging from 78 to 82 degrees Farenheit in communal areas. The Home was found to be clean and fresh during the inspections. One resident said “ The staff clean my bedroom every day”. However commode pots were not being cleaned effectively following use, one was noted to still contain urine after cleaning and this was brought to the attention of the Care Manager. Infection control audits are not undertaken. Staff transport clinical waste outside of the building to the external clinical waste bin collection area via the main public front entrance of the Home wearing contaminated gloves and this poses a serious risk of cross infection. The Inspector was informed that this was the only route to the clinical waste storage area and a risk assessment and infection control procedure had not been completed in respect of this practice. The Commission received a complaint that items of residents’ personal clothing were missing despite them being labelled. In addition to this, another resident met during the inspection said “ I have had an item of clothing missing for a long time and I have told the laundry staff about this” Clothing in residents’ wardrobes were found to be creased and poorly ironed. Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 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 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) 27, 29 & 30 Residents are not always supervised in the communal areas of the Home and this may pose a risk to their safety. With one exception, there are robust recruitment practices in place to ensure that residents are protected. Staff receive a comprehensive induction, however further training in some areas is required to ensure that residents are supported by trained staff. EVIDENCE: The staffing rotas identified that the Home were working within approved staffing levels and there was currently a vacancy for a kitchen and laundry assistant. Ancillary support is provided including a Maintenance Person, Administrator and Laundry, Domestic and Kitchen staff. Agency staff are used to cover periods of staff sickness and annual leave. The Care Manager provides on call support to the person in charge of the shift. The Commission had received a complaint that residents were left unsupervised in the lounges and this was found to be the case on occasions. One resident said “ we are not left on our own in the lounge” However other residents, visitors and staff met during the inspection stated that the lounges were not supervised at times due to staffing numbers. Staffing levels must be reviewed to ensure that residents are supervised in the lounges at all times. Staff allocation systems and records had been introduced. Staff files sampled contained all information as required by Regulations and pre employment health declarations were undertaken. Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 Page 20 Interview notes were kept and job descriptions and contracts of terms and conditions of employment were issued. Satisfactory criminal records clearance was obtained for all with the exception of one new member of staff who had recently commenced employment at the Home. New staff undertake an induction and this includes health and safety issues. Staff had undertaken training specific to their job roles including NVQ level 2 in care and administration, communication and report writing, enteral feeding, COSHH, venepuncture and wound management. Training had been available some months previously in respect of the protection of vulnerable adults and it is recommended that refresher training in this area be provided. Staff had not received training recently in respect of caring for people with dementia care needs and a training needs analysis had not been undertaken in respect of all individual staff Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 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 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) 31, 32, 33, 35, 36 & 38 Residents live in a Home that has had many management changes recently and the staff team is in need of consistent management support and guidance to ensure that a continual good standard of care is provided at the Home. The systems for resident consultation are good. Residents’ financial matters are safe guarded through robust accounting of personal allowances. All of the equipment used at the Home is checked regularly to ensure that it is safe to use. Staff had not received training in a number of health and safety issues and this may pose a risk to residents’ safety. EVIDENCE: A temporary Home Manager came into post on the day before the second inspection and the Inspector was assisted during the inspection by the Care Manager (who had been the previous Home Manager and had all relevant knowledge about the service provided at the Home). It is anticipated that Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 Page 22 senior staff will have clear lines of accountability once the permanent management team is in place. Residents and relatives meetings had recently been introduced at the Home and this was well supported. Staff meetings are also held regularly and the minutes of these were available. Staff training is planned in respect of how to undertake the comprehensive quality assurance system, therefore this system is yet to be implemented at the Home. Quality monitoring visits are undertaken regularly by external Managers. The staff do not manage the personal finances of residents, with the exception of the safe keeping of their personal allowances as requested. The system for the management of this was good, a safe facility was available, separate transaction records were maintained and receipts of all personal items purchased out of residents’ money were available. This system was audited regularly. A system for formal staff supervision and appraisal had not been implemented. Appropriate magnetic closures had been fitted to fire doors as required, however the treatment door was wedged open at the time of the inspection. Staff had undertaken fire safety training, however training was required in respect of moving and handling, health and safety, infection control and food hygiene. A fire drill had been undertaken recently. Health and safety checks had been undertaken in respect of equipment used at the Home including portable electrical appliances, hoisting equipment, the fire alarm and emergency lighting systems and laundry equipment. Accident records did not include detail of any follow up action taken following an accident in order to minimise the risk of a reoccurrence and accident audits were not undertaken. There was however, evidence that appropriate medical advice was sought following accidents involving residents as required. Plans were in place for audits to be undertaken in respect of the incidences of falls involving residents. Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x 3 x 3 2 2 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 2 x 3 2 x 2 Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 Page 24 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. 2. Standard OP1 OP1 Regulation 4 5 Requirement The statement of purpose must be updated to reflect the current service provided at the Home The service user guide must be amended to reflect current practice and be accessible to each resident (timescale of 01 July 2005 not met) The appropriate authorities must be informed of residents changing needs to ensure that their care needs can still be met at the Home The Home Manager received this in the form of an immediate requirement Personal care and key worker records must reflect the actual care afforded to residents The Home Manager received this in the form of an immediate requirement Care plans must always be updated to reflect current care regimes Care plans must include detail of how residents social needs will Timescale for action 04/01/06 04/12/05 3. OP4 14(2) 16/09/05 4. OP7 12(1) 15 15/09/05 5. 6. OP7 OP7 15 15 16(2)(m) 30/11/05 30/11/05 Page 25 Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 7. OP7 13(4) 8. 9. 10. OP7 OP8 OP9 12(1) 12(1) 13(2) be met and any communications with their families and friends Bed safety rail risk assessments and disclaimers must include detail of the risks involved in the use of these Care plans in respect of continence management must be recorded in more detail All residents receiving residential care must be weighed regularly Prescription labels must detail comprehensive dosage instructions The actual dosages administered in respect of variable dosages must be recorded on medication administration charts The Home Manager received these in the form of immediate requirements Medication must be signed for immediately following administration Reasons for non administration of medication must be recorded on medication administration charts There must be adequate intervals between medication rounds The medication trolley (for residents receiving residential care) must be locked and stored securely at all times when not in use The Home Manager received these in the form of immediate requirements Due to the high proportion of residents with dementia care needs, the Home Manager must 30/11/05 01/12/05 01/12/05 18/09/05 11. OP9 13(2)(4) 15/09/05 12. OP12 16(2)(n) 15/12/05 Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 Page 26 review the activities on offer having regard to the needs of these residents (previous two timescales of 28 April 2005 and 31 July 2005 not met) The activities co ordinator must develop an activities programme suitable to meet the needs of all residents living at the Home after consultation with these residents and/or their representatives The adult protection policy must 30/12/05 be amended to reflect Local Authority Multi Agency guidelines and the contact details of the appropriate local authorities to be notified in respect of any allegations or suspicions of abuse must be available The internal temperature within 05/11/05 the Home must be within comfortable limits and these temperatures must be monitored regularly The Home Manager received this in the form of an immediate requirement Commode pots must be hygienically cleansed using the mechanical sluicing disinfector facility after each use The Home Manager received this in the form of an immediate requirement A risk assessment must be undertaken and an infection control procedure must be written in respect of the current procedure for the disposal of clinical waste The Home Manager received this Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 Page 27 13. OP18 13(6) 14. OP25 23(2)(p) 15. OP26 13(3) 15/09/05 16. OP26 13(3) 11/10/05 17. OP26 16(2)(e) 18. OP27 18(1) 19. OP29 13(6) 19(1) in the form of an immediate requirement The current system for the laundry and ironing of residents personal clothing must be reviewed Staffing levels and staff allocation must be reviewed to ensure that residents are not left unsupervised in lounges for periods of time Satisfactory criminal records clearance must be obtained prior to new staff commencing employment at the Home (timescale of 26 April 2005 not met A training needs analysis must be undertaken in respect of all individual staff A formal quality assurance system must be implemented at the Home (timescale of 01 June 2005 not met) A system for formal staff supervision and appraisal must be implemented Fire doors must not be wedged open The Home Manager received this in the form of an immediate requirement All staff must receive statutory moving and handling and health and safety training The Home Manager received this in the form of an immediate requirement Staff must undertake training in respect of food hygiene and infection control All accidents involving residents must be audited regularly and 01/12/05 01/12/05 30/11/05 20. 21. OP30 OP33 18(1) 24 30/12/05 31/01/06 22. 23. OP36 OP38 18(2) 23(4) 30/12/05 24. OP38 13(5) 18(1) 04/12/05 25. 26. OP38 OP38 18(1) 13(4) 04/01/06 30/11/05 Page 28 Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 detail of any follow up action taken to minimise the risk of further accidents must be recorded 27. 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 OP30 OP30 Good Practice Recommendations It is recommended that care staff undertake further training in respect of communication with older people and those residents with dementia care needs It is recommended that staff responsible for the care of residents receiving residential care undertake further training in respect of the residents personal risk assessments and care planning It is recommended that refresher training is provided for staff in respect of the protection of vulnerable adults The Organisation should further consider arrangements in respect of the external grounds facilities for residents living at the Home 3. 4. OP30 OP19 Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection Birmingham & Solihull Local 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 Berwood Court E54 S24824 BerwoodCourt V245164 041005 Stage 4.doc Version 1.40 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!