Inspection on 19/10/06 for Bethrey House

This inspection was carried out on 19th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Bethrey House 05/08/08

Bethrey House 08/08/07

Bethrey House 06/02/07

Bethrey House 15/08/05

Bethrey House 19/04/05

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 Bethrey House Bethrey House 43 Goldthorn Hill Penn Wolverhampton West Midlands WV2 3HR Lead Inspector Joy Hoelzel Key Unannounced Inspection 19th October 2006 09:15 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 Bethrey House DS0000020882.V297478.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. Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bethrey House Address Bethrey House 43 Goldthorn Hill Penn Wolverhampton West Midlands WV2 3HR 01902 338213 01902 338213 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) Quality Homes (UK) Limited Helen Kathleen Sims Care Home 18 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (18) of places Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Females aged 60 years and above and males aged 65 years and above. The home can accommodate (seven) 7 people over 65 with mild dementia (DE (E) 15th August 2005 Date of last inspection Brief Description of the Service: Bethrey House was built as a detached private dwelling around the turn of the century. It was first registered as a residential care home in 1981. Since then, the home has undergone a number of extensions and alterations. The home now provides accommodation and personal care for 18 older people. There is a car park at the front of the property and a patio and garden at the rear. The home is situated approximately two miles from Wolverhampton city centre and is on a main bus route to the city centre. There are local shops and amenities less than a quarter of a mile from the home Weekly fees range from £336.00 - £ 385.00. Information of the home and the provision of the service are available in the statement of purpose and service user guide. Commission for Social Care Inspection reports for this service are available from the provider or can be obtained from www.csci.org.uk Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection is the first of key inspections for 2006/07 and took place over seven and quarter hours on Wednesday 19th October 2006. It was conducted by one Commission for Social Care Inspection regulation inspector. Twenty seven of the thirty eight National Minimum Standards for Older People were inspected. Sixteen people are currently living at the home with two people expected to arrive during the day for short term respite care. The registered manager was on the premises and in charge of the building and was supported by three care staff with additional domestic and catering staff. The owner visited the home during the inspection. Three case files were selected for case tracking, relevant documents were inspected, and discussions were held with visitors and members of staff. Very few of the current service users were/are unable to comment due to cognitive difficulties, the comments made by some people are included in this report. Observation was made of the various daily activities and a tour of the premises was conducted. Staff members, one resident and one visitor completed five on site survey cards. What the service does well: What has improved since the last inspection? What they could do better: Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 6 Three requirements made following the last inspection in August 2005 have yet to be fully complied with and are in relation to the redecoration of the first floor corridor, the repair of the shower and full compliance with the fire officer’s recommendations. At this inspection, it was found that the home is failing to provide a good service across most areas covered by the National Minimum Standards. It was found that care planning systems were not good enough to ensure that people received the care they need and medication was not being managed properly. People living at the home are not provided with opportunities to take part in activities and the way the home operates offers little choice in important things like how people spend their time or what they eat. Service users are being put at risk by the home not checking new employees before they start work and by not providing training for staff. Although the home is comfortable, hygiene and safety are not being promoted and the welfare of people living at the home is not being adequately protected. 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. Bethrey House DS0000020882.V297478.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 Bethrey House DS0000020882.V297478.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 1,3,6 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. The service consults the assessment information to see if they can meet the prospective residents needs before they make the decision to accept the application for admission and offer a placement. Evidence suggests that prospective residents have a needs assessment carried out before they are admitted to the home. EVIDENCE: The home has produced a statement of purpose and service user guide detailing the service provision and states a review date of 01/03/05. Further amendments are required to ensure that all information contained in the documents is current and correct. Pre admission assessments of a persons care needs are undertaken prior to making the decision to move into the home. Copies are kept in the case file and include the homes own assessments together with assessments from the local primary care trusts and the local authorities. The manager explained of Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 9 two expected admissions on the day of the inspection, information was available for formulating the care plan at the point of the admission. One person arrived, was greeted by the manager and shown to her allocated room and other areas of the home. The home does not offer an intermediate care service. Bethrey House DS0000020882.V297478.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 7,8,9,10 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. The care plans do not provide sufficient information on the assessed care needs and without this there is no guarantee that care needs are being fully met. The homes systems for medication administration are currently unsafe; amendments are required to ensure that a safe system of medication administration is adopted. EVIDENCE: Three case files were selected for inspection and included the plan of a person most recently admitted to the home, the other persons had been resident for a period of time. All residents had a plan of care that is initially generated from the pre admission assessments. The care plans and risk assessments are not being reviewed on a monthly basis or when a change of need has been identified. The care plans had not been signed by the resident or relative/representative although it is acknowledged that some people may not wish or are unable to contribute with this care planning process. Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 11 One initial care plan identified some care needs in relation to bathing, maintaining personal hygiene and adequate nutrition. Specific care plans had not been formulated setting out the details of the action to be taken by staff to fully meet the care needs. This person also required insulin injections for diabetes and was self-administering the injections with ‘ supervision’ from staff. A risk assessment had not been carried out for this task, the competency of the person or staff had not been assessed (this person has an identified short term memory problem) and clear instructions for staff were not available. A care plan detailing the times of the injections, the frequency and required levels of the blood sugar monitoring or what to do in the case of an emergency had not been completed. There are no records of monitoring and ensuring an adequate diet is taken on a daily basis. Another case file contained a document for ‘special instructions’ detailing that ‘cream to be applied to legs’ no further instructions had been made as to the type of cream to be used, the frequency of the application or what staff must do when an improvement or deterioration of the area is identified. The manager has introduced a document for the psychological assessment of a person this included some relevant information of a persons mood etc. however this document although completed in one care plan was not dated, signed or a date for review identified. The daily reports are completed well with details of the happenings of each day. Some of the residents looked unkempt giving the impression that staff give very little time and attention to detail when assisting residents with dressing and grooming. The home operates a twenty eight day regimen for the administration of medication using the nomad system with the additional use of some bottles and boxes. The drugs trolley is stored in the main dining area; it is not chained to the wall when not in use. Other surplus medications are stored in a drawer in the filing cabinet in the office. Throughout the time of the inspection this cabinet was not locked. The drugs trolley and drawer in the filing cabinet both contained external and internal preparations and requires to be sorted with any surplus or no longer required medications being returned expediently to the pharmacist for disposal. During the afternoon the following months supply of medication was received into the home. This was not locked away safely but was placed in a box on the floor in the office. The office was locked by the manager on her departure from the home. The manager explained that there are no allocated storage areas or cupboards available for the storing of medications. Medications requiring cold storage are placed in a plastic box in the fridge in the main kitchen. This box on observation did not have a lid or labelled to state that medications are stored inside. A separate lockable fridge is urgently required for the safe storage of such medications. During the tour of the premises, in the bedrooms, some external creams were in use and had not being dated upon opening, the deputy was advised to introduce this practice and discard tubs of creams after one month of opening and tubes of ointments after three months of opening. Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 12 The Medication Administration Records appear to be satisfactorily completed, an explanation is made when medications are refused or not given. A photograph on the divider between the Medication Administration Record is required to aid ease of identification. The manager confirmed that staff have received training in the safe administration of medication at the beginning of October 2006. Certificates of achievement have not yet been received. The safe storage of the medication was discussed with the manager, area manager and owner of the home. A quiet lounge on the first floor is available for use should someone wish to have ‘space’ or privacy with visitors. The manager stated the room is used very little. Not all toilets and bathrooms have a suitable locking facility or vacant/engaged indicators to ensure the privacy in using the facilities is upheld. Very little interaction was observed during the day between staff and residents, there was not much conversation or chatter happening. Bethrey House DS0000020882.V297478.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 12,13,14,15 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. Activities are extremely limited, there appears to be no dietary choice and there is no evidence that service users’ lifestyles reflect their social or cultural interests or needs. EVIDENCE: Two of the care staff team are allocated the additional tasks of arranging and organising social and leisure activities. The manager stated that no additional hours are allocated for this. Very little activity occurred during the day of the inspection. The television was on in the large lounge the whole of the morning with a Daniel O Donnell video for the afternoon. All of the residents were sitting in the main lounge in their chairs, which are placed around the room. People sitting to the side, or at the top end of the room had very little opportunity to watch the television even if they wished to do so. Interaction between staff and residents was observed at the routine drink and meal times or when assistance was required to go to the toilet. The notice board in the main entrance to the home displayed a poster of an activity that had taken place in July and information that bingo would be arranged each week. No newspapers or magazines were seen. The manager explained that a Roman Catholic priest visits about every two weeks to see one resident. Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 14 It is acknowledged that some residents may not wish or are unable to partake in any structured activity nevertheless opportunities for stimulation through leisure interests both inside and outside the home must be available and age appropriate. One resident stated that they would like to go to the local pub occasionally for ‘a pint’ but had never been offered the opportunity to go. The statement of purpose states ‘ we try to make it possible for our residents to live their lives as fully as possible ………….to enjoy a wide range of individual and group activities………….. we try to arrange at least one outing each month …….we have daily newspapers.’ One person was visiting and completed the on site survey, indicating that ‘staff interact well with residents and relatives and they try to encourage interaction to promote a pleasant environment’. The manager stated that the home is usually quite busy with people visiting and that they are welcome to visit at times suitable for the resident. One resident stated that family members visit regularly each week and the visits were ‘very enjoyable’. The manager discussed the possibility of accessing the advocacy service for one resident who had no family or friends to act on their behalf. During the tour of the premises many of the bedrooms were individualised with personal belongings. There appeared to be limited choices available to some of the residents. At lunch time staff only offered a choice of dessert to residents when it was noticed that the inspector was sitting at the table. Two residents stated that they are not offered a choice of meal however during the afternoon staff were observed to be asking residents of their choice of tea – tomatoes on toast or sandwiches. One resident spoke of satisfaction with the breakfast provided each day and commented that ‘it is the best meal of the day’. Some residents were sitting at the dining table for lunch whilst others were in the lounge; residents stated that the meal was ‘good’, ‘ok’, ‘ could be better’. Bethrey House DS0000020882.V297478.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16,18 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. There are no policies and procedures available in regard of the protection of residents and there is a lack of awareness within the management of the service of the latest regulations, results of enquiries or external guidance. Without this there is no guarantee that residents are being adequately protected from harm. EVIDENCE: The service user guide contains details of the homes complaints procedure. Information on how to contact Commission for Social Care Inspection must be amended with the correct details. The complaints log did not record any recent complaints and the manager stated that no complaints had been received. One resident informed the inspector of a recent complaint made to the manager with the social worker being contacted and visiting the home to discuss the concerns. The area manager explained that the manager had only become aware of the concerns the day before the inspection and had not had the opportunity for recording it. No complaints/concerns have been raised directly with the Commission for Social Care Inspection since the last inspection in January 2006. The home does not have a policy or procedure for the protection of vulnerable adults. It was recommended to the manager that contact be made with the vulnerable persons coordinator in Wolverhampton for advice on formulating a procedure. Individual records are kept for the safe keeping of residents monies held on their behalf. Two records were randomly selected, the amount recorded and Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 16 the actual cash did not tally on both accounts with a discrepancy of £2.00 and £7.00 respectively. The manager could not account for the shortfalls. Transactions are recorded with receipts given, at present only the manager signs for the transactions. No written procedures are available. It was discussed with the manager the need for two signatures at all times and the need to have a monthly audit to ensure the accuracy of the transactions during the month. Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP19, 21,22, 26 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable place for people to live however the environment and equipment within the home are not being maintained safely EVIDENCE: A full tour of the premises was conducted with the manager. A conservatory had recently been installed providing additional communal space. An external assessor was using the area for meeting with staff currently undertaking National Vocational Qualification training. The manager stated that the area is used very little by the residents and will not be during the winter months as no heating has been installed. A sign or similar is needed to be placed on the patio doors to reduce the risk of bumping into the doors when they are closed. The main lounge and dining area have been furnished with domestic type furniture and appear to be suitable for the resident group. Two residents stated that they were ‘quite comfortable’. Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 18 The corridor on the first floor has been painted under the dado rail, the wallpaper has not been changed, and some of the border has been torn off. Some doors around the home were being kept open with the use of wedges, where there is a need or personal preference for doors to remain open then the appropriate door closures must be fitted that are linked into the fire alarm system so as to close effectively when the alarm is activated. Some bedroom doors did not close effectively when being shut offering no protection should a fire occur. The manager stated that the handyman would be instructed to check all doors to ensure that the door closures are adjusted to close properly. Many of the bathrooms, toilets and ensuite facilities had wooden type toilet seats that are not easily cleanable and many toilet bowls were very soiled. Extractor fans in these areas were not working. The enamel on the side of the bath was chipped and in need of repair or replacement. The bath hoist/chair in use in this bathroom had been previously repaired and is now in need of further repair or replacement. The manager stated that the shower room was very little used as there is a risk of slipping on the tiled floor when wet as the ramp at the entrance to the room is very steep, the extractor fan was also not working. The area would benefit from a complete refit. The bathroom on the first floor is fully carpeted consideration should be given to replacing the flooring with a more suitable easily cleanable type. The hot water temperature at outlets accessible to residents cannot be assured as a safe temperature, thermometers for testing the temperature on a regular basis are not available. It was highly recommended that thermometers are purchased without delay and regular testing is commenced. In each bathroom there was evidence of communal toiletries and pots of creams (Sudocrem, aqueous cream), the manager was instructed to immediately remove all items and ensure that each person has their own supplies, which are then kept in the individuals bedrooms. Bars of soap, cloth hand towels and nail brushes were in use at most communal and private wash hand basins. There was no provision of paper towels, liquid soap or a foot operated lidded disposal bin for staff and visitor use to reduce the risk of cross infection. Not all bathrooms and toilets had a suitable locking facility or vacant/engaged indicators; this may compromise a person’s privacy when using these facilities. Commodes are in some bedrooms for night time use, the manager explained the procedure for disposing and cleaning of the commodes with the use of the domestic type sink situated in the laundry. A sluice facility is not available. It is strongly recommended that a sluice disinfector be purchased to reduce the risk of cross infection and to reduce the risk to staff of splash back accidents. The member of staff dealing with the laundry described the procedures for dealing with soiled linen, again this is being hand sluiced in the sink in the laundry. For the prevention of cross infection this practice must cease immediately, alginate type bags must be available for staff use. It was not possible to establish whether the washing machine has a dedicated sluice cycle to ensure that staff have as little contact with soiled linen as possible. Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 19 Two sets of bedrails are in use, no regular checks are being carried out to ensure that they are correctly fitted and remain fit for purpose. The manager was asked to take immediate action to ensure the safety of the bedrails. There are no bedrail covers or ‘bumpers’ available which significantly reduce the risk of injury to the person when in bed. Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 27,28,29,30 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. The service has a poor recruitment procedure with shortfalls in recording and process being evident and has the potential for putting residents at great risk by employing staff that have criminal convictions. EVIDENCE: On the day of the inspection the manager was supernumery and was supported by three care staff with additional catering and domestic personnel. The staff numbers are reduced for the evening and night time periods to two care staff. The manager explained the on call arrangements for when staffing levels are reduced in case of emergencies. Three staff personnel files were selected for inspection and included new and existing staff. All three files did not contain the required references and two did not contain a protection of vulnerable adults first check, criminal record bureau disclosures or any other identity checks. A person had recently been recruited in the position of cook but did not have the food hygiene certification. The manager stated that training is being arranged. There was no evidence of any structured induction training for new staff. The current statement of purpose does not offer any information of the staff group, their qualifications or training opportunities. Only one of the personnel files contained certificates and records of achievement in National Vocational Qualification level 2 in care, diabetes awareness, first aid and safety in the administration of medication. Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 21 The area manager stated that currently staff are training in infection control and when that course is finished opportunities will be offered for training in other areas. It was not possible to establish the ratio of staff trained at National Vocational Qualification level 2 or the equivalent. Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 31,33,35,36,37,38 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. The home is failing to maintain systems to manage the home effectively or safely and is not operating in the best interests of people living at the home. The results of working practices do not promote and safeguard the health, safety and welfare of service users or staff. EVIDENCE: Since the inspection in August 2005 the then manager has left the home to move into other employment. A replacement has been recruited and has been in post since December 2005. She is currently working through the National Vocational Qualification level 4 in care and management with a planned completion date of December 2006; the manager is then planning further training on the Registered Managers Award. Residents / relatives questionnaires were distributed in June 2006. The completed forms are currently being audited at another home in the company. Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 23 Staff meetings appear to be sporadic the last one being held in May 2006, the manager stated that another meeting would be organised shortly. She went on to say that a residents meeting previously arranged had not been too successful as many people did not wish or were unable to contribute to the meeting. A date for a further meeting has not yet been identified. The area manger conducts the monthly unannounced visit to the home and prepares a report; the manager stated that she has not received a copy of the report. A copy of the report must be available at the home and available for inspection if requested. Individual records are kept for the safe keeping of residents monies held on their behalf. Two records were randomly selected the amount recorded and the actual cash did not tally on both accounts with a discrepancy of £2.00 and £7.00 respectively. The manager could not account for the shortfalls. Each transaction is recorded with receipts given, at present only the manager signs for the transactions. No written procedures are available. It was discussed with the manager the need for two signatures at all times and the need to have a monthly audit to ensure the accuracy of the transactions during each month. The manager accepted that formal supervision at least six times a year together with an annual appraisal of work performance is outstanding for all levels of staff. A record is not maintained of the diet offered to residents on a daily basis, ensuring there is sufficient evidence of maintenance of good nutrition. Records for the regular monitoring of health and safety systems were available, but evidencing that the portable appliance testing is outstanding with the date for the annual testing being 12/08/06. The last recorded date for the weekly testing of fire alarm, emergency lighting and fire hydrants was 26/08/06. No records are being kept of the random regular testing of the hot water outlets or the annual testing for the prevention of Legionella. It was not possible to determine whether a full fire risk assessment had been carried out for the premises. General risk assessments were carried out in September 2005. Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 24 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 2 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X 2 2 X X X 1 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 1 1 1 1 Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 4(1) 5(1) Requirement The statement of purpose and service user guide must be reviewed to contain all relevant information, be readily available and in the appropriate format. The registered person must ensure all care plans are reviewed on a monthly basis or when a change of need has been identified. The registered person must ensure that whenever possible the resident and/or representative are fully involved with the care planning process. The registered person must ensure all care plans set out in detail the action required to be taken by staff to ensure that the health, personal and social care needs of a person are fully met The registered person must ensure that risk assessments are carried out and include nutritional and psychological screening, tissue viability and falls risk assessments must be undertaken and reviewed at regular intervals. DS0000020882.V297478.R01.S.doc Timescale for action 01/01/07 2 OP7 15(1) 30/11/06 3 OP7 15(1) 30/11/06 4 OP7 15(1) 30/11/06 5 OP8 12(1)(a) (b) 30/11/06 Bethrey House Version 5.2 Page 26 6 OP9 13(2) 7 OP10 12(4)(a) 8 OP12 16(2)(m) (n) The registered person must ensure that the procedures for the receipt, storage, administration and disposal of all medications are revised and safe systems are adopted. The registered person must ensure that all bathrooms and toilets have a suitable locking facility with vacant/engaged indicators. The registered person must ensure opportunities for stimulation through leisure interests both inside and outside the home are available and age appropriate. The registered person must ensure that residents are supported and encouraged to exercise choice and control over their lives The registered person must ensure that systems are in place for the recording of all concerns and complaints. The registered person must ensure the home has policies and procedures in place for dealing with the protection of vulnerable adults. The registered person must ensure that policies and procedure for dealing with service users personal monies are developed and implemented. The registered person must ensure that a full programme of the routine maintenance and renewal of the fabric and decoration of the premises is produced and implemented with records kept. The registered person must ensure that the first floor corridor is redecorated. Previous requirement DS0000020882.V297478.R01.S.doc 30/11/06 01/01/07 01/01/07 9 OP14 12(2) 30/11/06 10 OP16 22 30/11/06 11 OP18 12(1)(a) 30/11/06 12 OP18 12(1) 30/11/06 13 OP19 23(1)(2) 30/11/06 14 OP19 23 (2) (b) 01/01/07 Bethrey House Version 5.2 Page 27 01/03/06. Not fully met. 15 OP21 23 (2)(b) The registered person must ensure that the thermostatically controlled mixer valve on the ground floor shower is repaired or replaced. Previous requirement 01/03/06. Not met. The registered person must ensure that a full assessment is required to ensure that all bedrails in use are safe and fully suitable for the purpose. The registered person must ensure that for effective control of infection suitable hand wash facilities (paper towels, liquid soap and a lidded disposal bin) must be provided at the point of the delivery of care. The registered person must ensure that effective procedures are developed and implemented for the safe disposal of bodily waste and dealing with soiled linen. The registered person must ensure that infection control policies and procedures are developed and implemented. The registered person must ensure that a minimum ratio of 50 of care staff are trained to National Vocational Qualification Level 2 or equivalent The registered person must ensure that the recruitment procedures are fully revised and that a robust system is implemented. The registered person must ensure that all staff receive training in the core topics and any specialist areas relating to the client group and area of work The registered person must ensure that the registered DS0000020882.V297478.R01.S.doc 30/11/06 16 OP22 13(4)(c) 30/11/06 17 OP26 13(3) 30/11/06 18 OP26 13(3) 30/11/06 19 OP26 13(3) 30/11/06 20 OP28 18(1) 01/01/07 21 OP29 19 30/11/06 22 OP30 18(1) 01/01/07 23 OP31 9(2) 31/12/06 Page 28 Bethrey House Version 5.2 24 OP35 17(2) Schedule 4 (9) 25 OP36 18(1)(c) (i) 26 OP37 17(2) Schedule 4 (13) 27 OP37 17 28 OP38 12(1) 29 OP38 23 (4) (a) manager completes the National Vocational Qualification level 4 in care and management. The registered person must ensure that a safe system is adopted for the safekeeping of service users personal monies. Accurate records must be maintained. The registered person must ensure that all staff receive formal and recorded staff supervision at least six times a year and in an appropriate format together with an annual appraisal of their work performance. The registered person must ensure records of food provided for residents are in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory The registered person must ensure that all records required by regulation for the protection of residents and for the effective and efficient running of the home are maintained, up to date and accurate. The registered person must ensure that all weekly, monthly and annual checks are carried out with records kept The registered person must ensure that all recommendations in the Fire Prevention Officers report dated 21/12/05 are implemented. Previous requirement 01/03/06. Not met. The registered person must ensure that all risk assessments are carried out for safe working practice topics; the findings recorded and actioned and the DS0000020882.V297478.R01.S.doc 30/11/06 01/01/07 30/11/06 01/01/07 30/11/06 30/11/06 30 OP38 12(1) 01/01/07 Bethrey House Version 5.2 Page 29 assessments are reviewed at regular intervals. 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 OP9 Good Practice Recommendations It is strongly recommended that all external medications be dated upon opening with tubs of creams/ointments discarded after one month of opening and tubes after 3 months of opening. It is strongly recommended that contact be made with the vulnerable persons coordinator in Wolverhampton for advice on formulating a procedure in adult awareness and the protection of vulnerable adults. It is strongly recommended that consideration be given to the complete refurbishment of the shower room. It was strongly recommended that thermometers are purchased without delay and regular testing of the hot water outlets is commenced. It is strongly recommended that a sluice disinfector be purchased to reduce the risk of cross infection and to reduce the risk to staff of splash back accidents. It is strongly recommended that bed bumpers are purchased and used in conjunction with the bedrails to reduce the risk of injury to the person when in bed. 2 OP18 3 4 5 6 OP21 OP21 OP26 OP22 Bethrey House DS0000020882.V297478.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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. 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