Inspection on 26/02/07 for Bethany House

This inspection was carried out on 26th February 2007.

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

Bethany House 29/08/07

Bethany House 28/11/06

Bethany House 31/10/05

Bethany House 11/05/05

Bethany House 02/11/04

Bethany House 19/05/04

Bethany House 12/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Bethany 434/436 Slade Road Erdington Birmingham West Midlands B23 7LB Lead Inspector Kulwant Ghuman Key Unannounced Inspection 26th February 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bethany DS0000016765.V328597.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Bethany DS0000016765.V328597.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bethany Address 434/436 Slade Road Erdington Birmingham West Midlands B23 7LB 0121 350 7944 0121 624 7311 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) Mr Joseph Alphonse Rodrigues Mrs Helen Rodrigues Mr Joseph Alphonse Rodrigues Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30) of places Bethany DS0000016765.V328597.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That one named person, who is under 65 years of age at the time of admission can be accommodated and cared for in this Home. 28th November 2006 Date of last inspection Brief Description of the Service: Bethany House is a registered care home for 30 elderly people and is located North of the City Centre in Erdington and close to the M6. It has easy access to community facilities and public transport which runs directly outside the home. The home was originally four houses that have been tastefully converted into one large care home offering a very good standard of accommodation. Accommodation is offered over two floors with six double and eighteen single bedrooms all with en-suite toilet and wash hand basins. There are three lounges and a large dining room located on the ground floor, toilet, bathing and showering facilities are located throughout the home. There is also a hairdressing room, large kitchen with a small area attached for residents to prepare drinks, medical room, laundry and office space. The front of the home has been block paved and has ramped access and ample parking space. To the rear of the home is a very large patio area that has been block paved to match the front and offers ample space for the residents with a water fountain feature, raised flower beds and seating available. Access to the grounds is via the dining room and three bedrooms on the ground floor have direct access to the grounds. The fees at the home range from £314 to £420.26. Bethany DS0000016765.V328597.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this key unannounced inspection over one day in February 2007. As part of the inspection a partial tour of the building was undertaken, three staff, the manager and one resident were spoken with. Three resident and four staff files were sampled along with other care and health and safety records. No complaints had been received about the service since the last inspection in November 2006. What the service does well: What has improved since the last inspection? Since the last inspection the pre-admission assessment of residents had been improved to ensure that residents needs could be met by the home. Care plans and some risk assessments had been updated. The complaints procedure and service user guide had been updated and were available in the home. The residents identified at the last inspection had been referred to the dietician and improvements had been made in the weight and general well being. The issue of privacy in one of the resident’s bedrooms had been attended to. Bethany DS0000016765.V328597.R01.S.doc Version 5.2 Page 6 Suppers were being offered to residents. The bath in one bathroom was being replaced at the time of the inspection. The staff had undertaken some training and the staff-training matrix had been updated. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bethany DS0000016765.V328597.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Bethany DS0000016765.V328597.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission procedure had improved significantly since the last inspection. The home needed to ensure that the assessment carried out by the placing authority was received before residents were admitted to the home to ensure that the home could meet their needs. EVIDENCE: There were copies of the updated service user guide and statement of purpose available in the home. The home agreed that the contract would be amended to include a section for residents or their representatives to sign that they had received a copy of the service user guide. The file of one new resident was sampled to assess the admission process. Since the last inspection a new assessment form had been introduced into the home that covered many areas of need, daily routines and issues that the Bethany DS0000016765.V328597.R01.S.doc Version 5.2 Page 9 home needed to be aware of that could upset the resident. This assessment had been carried out on the day of the pre-admission visit to the home. There was a social work care plan and single assessment available in the home but the inspector was informed that this was not received prior to the resident’s admission to the home. It is important that this information is obtained before residents are admitted to the home to ensure that the home have all the information they require to enable them to ensure that they can meet the residents needs. There was a third party funding agreement with the local authority in place and a copy of the signed terms and conditions of residence from the home. The resident identified at the last inspection of not having a contract in place had been provided with one. Bethany DS0000016765.V328597.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plan documentation and risk assessments were being updated to ensure that residents’ needs were being identified and planned for. Residents’ health care needs were being followed up and referrals to the appropriate professionals made. Some aspects of the administration of medicines needed to be improved. EVIDENCE: The care documents of the files sampled at the previous inspection were sampled to ascertain whether improvements had been made to them. Some improvements had been made to the care plans but not all the information given verbally by the staff had been included in the care plans. For example, one of the files did not record that the staff were undertaking some exercise routines to develop strength and mobility in the arms and the staff were no longer standing the resident up every two hours when sitting in Bethany DS0000016765.V328597.R01.S.doc Version 5.2 Page 11 the lounge. During sampling of the turn charts in the resident’s bedroom it was noted that the resident was not being turned onto the right side due to a blister developing on the hip, this was not recorded anywhere. It was important for this information to be recorded so that all the staff were aware of the tasks to be undertaken and the reasons why they were or were not being undertaken. The file had been updated to include information about the use of elbow and heel muffs in bed and the use of a pro-form mattress and cushion to sit on in the chair and that the resident was on a soft diet. The file stated that bed rails were in use but there was no risk assessment in place for their use and how any accidents would be minimised. Other risk assessments had been updated. One of the residents case tracked during the previous inspection had moved to another home and the third file did not state what the plan to minimise the risk identified by a Waterlow assessment was. It was acknowledged that there had been some improvements in the files being updated and that it was work in progress. Examination of the weight records indicated that the resident identified at the previous inspection was putting on weight and the dietician and GP had been consulted about the weight loss. There was a discussion with the manager regarding the general monitoring of the residents’ weights. The manager stated that residents would be referred for medical follow up if their weights fell into an underweight or obese range. It was important that the home was proactive in keeping an overview of weight loss or gain and refer for medical advice, and consider other reasons that may be contributing to unintentional weight changes, before it became a problem. Examination of the medication procedures showed that the management of medicines administered via the monitored dosage system were managed well. However, a sampling of boxed medicines indicated that the prescribing instructions had not been changed when the amounts being administered had been changed. For example, the MAR chart stated 2 painkillers were to be given 4 times a day for a resident however this had changed to 2 times a day. Also the resident’s Quietipine had changed from one at night to two at night. Some of the medicines had not been booked in and therefore an audit trail could not be carried out. There were some examples of there being either too many or too few tablets left in the boxes when an audit of the boxed medicines was carried out. Eye drops were not always being dated on opening. Bethany DS0000016765.V328597.R01.S.doc Version 5.2 Page 12 Staff could not locate the records for the homely remedies. At the last inspection there was evidence that staff were able to observe a resident through a glass panel in an interconnecting door between two bedrooms. This compromised the resident’s privacy. Since the last inspection this glass panel had been blocked off so that the resident’s privacy could not be compromised. No further concerns about the privacy and dignity of the residents were raised at this inspection. Bethany DS0000016765.V328597.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were no rigid rules in the home, visitors were welcomed, and residents were encouraged to make some choices. Residents stated they were happy with the food provided. EVIDENCE: The activities sheets showed that there were regular activities organised including bingo, tea dances, exercise and so on. During conversation with one of the residents it was stated that the resident had not been out for some time and would like to go out. It was determined by a member of staff that the resident should have been taken out before Christmas and this had not happened. The manager stated that several of the residents went out with their relatives. It was important that residents who did not have relatives who could take them out be given this opportunity with staff and that although there were in-house, group activities there also needed to be individualised activities for the residents. Bethany DS0000016765.V328597.R01.S.doc Version 5.2 Page 14 During the day the inspectors were informed that the staff had undertaken some exercises with the residents and some residents were seen be walking around the home. Following consultations with the residents about social activities individual plans needed to be made so that residents’ needs could be met. The menu in place was the same as the one sampled at the last inspection. The menu indicated that Tuesdays, Thursdays, Fridays and Saturdays the meals were set, however Sundays, Mondays and Wednesdays the menu changed depending on which week it was. For example, on Wednesday Week 1 and 3 it was Faggots on the menu and during weeks 2 and 4 it was shepherds pie. An alternative lunch option was identified on the menu however, the food records showed that it was rare for anyone else to have the alternative. Some alternatives were identified and sometimes taken up at evening tea. The inspector was informed that since the last inspection suppers had been introduced however a form for recording this had not yet been implemented. The food records and daily records indicated that on occasions it had been recorded that supper had been provided but this was not recorded on a consistent basis. The menus needed to identify what the alternatives for residents with diabetes were and also any special diets being catered for so that all staff in the kitchen were aware of the residents’ needs. Lunch was not sampled or observed during this inspection. One of the residents spoken with during the inspection stated that they were happy with the food provided. Fresh fruit and vegetables were available in the kitchen. There were plentiful supplies of frozen foods in the fridge and freezers and the meats were all dated. One supplier made a delivery during the inspection and another delivery was expected. Bethany DS0000016765.V328597.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No complaints had been received about the home since the last inspection and the complaints procedure had been updated. Staff had been provided with adult protection training. EVIDENCE: No complaints or concerns regarding adult protection had been received by the CSCI about the service and none had been received by the home. The complaints procedure had been updated to make clear that complaints could be made to the CSCI at any point and the complaint procedure was on display in the home. Staff had had training in adult protection training and a procedure to be followed was on display in the home and was satisfactory. Bethany DS0000016765.V328597.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises were well maintained and provided the residents with a homely environment in which to live. EVIDENCE: Not all areas of the home were inspected during this inspection. There had been no changes to the layout of the home since the last inspection. It was safe accessible and very well maintained. The home had a very good standard of furnishings and fittings throughout that were domestic in character. The lounges were seen to be comfortable and homely. Bethany DS0000016765.V328597.R01.S.doc Version 5.2 Page 17 The home had a variety of aids and adaptations including handrails, assisted bathing facilities and ramped access to the home. There was a very large shaft lift which gave easy access to the first floor. There were grab rails in all the en-suite toilets. Doorways were wheelchair accessible and wheelchairs were available in the home. Some of the bedrooms had pressure pads installed that triggered the call system when residents who were at risk wandered around thus alerting staff. Eight bedrooms were sampled during this inspection and found to meet the needs of the residents. They were personalised with the residents’ belongings where possible. There were suitable locks on the bedroom doors. One of the bedrooms sampled did not have a lockable item of furniture for the residents to be able to lock away items of personal value. The inspector was told that the residents on the ground floor were unable to look after keys to their bedrooms but the staff locked the doors to prevent other residents wandering into the rooms. In one of the bedrooms the radiator had been removed due to a leak and additional heating had been placed in the room. There was no risk assessment in place for the heater which would become hot to touch. The inspector was informed that the radiator would be replaced in the next day or so. In the shower room on the first floor there was a tablet of soap, nail and hairbrush. These items needed to be returned to the residents’ bedrooms to comply with infection control procedures. One of the bathrooms on the first floor was in the process of having the bath replaced. Bethany DS0000016765.V328597.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. No new staff had been recruited directly by the home’s manager and therefore this aspect of recruitment could not be fully assessed. Significant progress had been made on the training for staff but manual handling training for staff remained outstanding. EVIDENCE: There were adequate numbers of staff on duty on the day of the inspection with three staff on duty. One staff member was due to arrive later and one was identified as being allocated to the kitchen. There was a core group of staff that remained at the home and some staff that were employed from overseas. Since the last inspection some staff had left and other staff that had been employed. The manager had experienced some language difficulties with one of the overseas staff. Four staff files were sampled during the inspection. Three of the files were for staff who had been employed from overseas and the recruitment checks had been undertaken by an agency. References and police clearances were carried out by the agency. Bethany DS0000016765.V328597.R01.S.doc Version 5.2 Page 19 There was no evidence to show that any of these staff had undertaken induction training. The fourth file was for a member of staff for whom references had now been obtained, however, the references were not dated and it was not clear in what capacity they knew the referee. Requirements made at the previous inspection in respect of the recruitment procedures have not been removed as there was no evidence to show that recruitment undertaken in this country was robust, that all checks were being taken prior to staff appointment and that recruitment processes were consistent regardless of the country of origin of the staff as no staff had been recruited by the manager. Two of the files showed that training had been undertaken in infection control, H&S, fire training, food hygiene, adult protection, dying/death/bereavement and dementia care. Manual handling training remained outstanding. Over 50 of the care staff had achieved NVQ Level 2 and the remaining staff had been registered to begin this training. Bethany DS0000016765.V328597.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Significant progress had been made on improvements in the management of the home but some areas remained outstanding. The home remained safe for staff, residents and visitors. EVIDENCE: This inspection was carried out to check on the progress made on the requirements of the last inspection carried out in November 2006 where several areas were identified for improvement. It was pleasing to note that several improvements had been made to these areas however, the management of medicines needed to be improved as some issues were identified at this inspection that had not been identified previously. Bethany DS0000016765.V328597.R01.S.doc Version 5.2 Page 21 At the last inspection problems had been identified with the recruitment procedures for staff appointed directly by the manager of the home. It was not possible to determine that this area had been adequately improved as the manager had not appointed any new staff since the last inspection although staff had been appointed from overseas via a recruitment agency. As identified at the previous inspection the management of health and safety at the home was good. The fire records and maintenance of equipment in the home was well managed. There appeared to be a good working atmosphere in the home between the staff and residents. The CSCI had been informed that the home had started work on a quality assurance system in the home but this was not assessed at this inspection. The home did not hold any money on behalf of the residents and any expenses incurred in the home were invoiced to the residents. Bethany DS0000016765.V328597.R01.S.doc Version 5.2 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 3 3 2 X 3 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 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 X 3 X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Bethany DS0000016765.V328597.R01.S.doc Version 5.2 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)(b) Requirement Timescale for action 01/05/07 2. OP7 15(1) The manager must ensure that a copy of the placing authorities assessment is received before a resident is admitted to the home. Care plans must include 01/06/07 sufficient details for staff to know what tasks a resident can undertake and what assistance they require and how it is to be given. Care plans must evidence that the resident or their representative has been involved in drawing them up. (Previous timescale of 01/02/07 partly met.) A review must be carried out 28 days after admission to ensure that the residents needs can be met by the home and that the resident is happy with the service being provided. (Previous timescale given 01/01/07. Not assessed at this inspection as timescale had not expired.) 3. OP7 15(2) 01/05/07 Bethany DS0000016765.V328597.R01.S.doc Version 5.2 Page 24 4. OP8 12(1)(a) An action plan must be in place for all cases where a risk has been identified by the Waterlow assessment. Pressure risk assessments must be updated and include the most recent actions being taken by staff. Risk assessments must be in place for all identified risks with strategies to manage them. (Previous timescale of 14/01/07 not met.) Residents losing or gaining weight unintentionally must be referred to the GP or dietician to have this change in weight investigated. (Partly met.) The home must develop a selfadministration medication policy. (Previous timescale given 01/02/07. Not assessed for compliance at this inspection.) Audits of the boxed medicines must be carried out to ensure they administered as prescribed. All medicines received into the home must be checked against the prescription and booked in. Eye drops must be dated on opening and discarded after 28 days. 01/05/07 5. OP9 13(2) 01/05/07 6. OP12 16(2)(n) The manager must ensure that records are available for the homely remedies. The home should consult the 01/05/07 residents on activities they would like on a group and individual basis. (Not assessed for compliance during this inspection as the DS0000016765.V328597.R01.S.doc Version 5.2 Page 25 Bethany 7. OP15 Sch3(3) (m) 8. 9. OP15 OP19 Sch 4(13) 23(2)(p) timescale of 01/03/07 had not yet expired.) The residents must be consulted about supper and records maintained of food offered and taken up by residents. (Partly met.) Food records must identify any special diets being provided. The manager must ensure that there is adequate heating in all bedrooms. 01/03/07 01/03/07 01/04/07 10. 11. OP19 OP26 23(2)(m) 13(3) Any additional heating in the home must be risk assessed. The manager must ensure that 01/04/07 all residents have a lockable facility in their bedrooms. Tablets of soap and nail brushes 01/04/07 must be removed from communal washing facilities after use. (Previous timescale of 01/01/07 not met.) Two references must be obtained 01/06/07 for staff prior to their commencing their employment. References must be dated and the capacity in which the staff was known to the referee recorded. No staff must be employed before references and POVA first checks have been received. Recruitment processes must be consistent regardless of the country of origin of the staff. There must be records maintained of the initial induction training staff receive when commencing their employment. (Previous timescale of 01/12/05 and 01/01/07 not met.) DS0000016765.V328597.R01.S.doc 12. OP29 19(1)(a) (b) Sch 2 13. OP30 18(1)(a) 01/06/07 Bethany Version 5.2 Page 26 14. OP33 24(1)(a) (b) The manager must ensure that staff complete their induction within 12 weeks of taking up employment. The home must have a formal quality assurance system based on seeking the views of the residents. (Previous time scales of 01/08/04, 01/07/05 and 01/02/06 not met.) 01/04/07 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 OP2 OP12 Good Practice Recommendations The contract should be amended to include a section to indicate that the resident or their representative had received a copy of the service user guide. It was strongly recommended that the activity records were developed to include comments from the residents on their suitability and include who had declined to take part. It is recommended that supervision records are developed to include some of the comments made by both supervisor and supervisee. 3. OP36 Bethany DS0000016765.V328597.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bethany DS0000016765.V328597.R01.S.doc Version 5.2 Page 28 - 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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