Inspection on 06/02/07 for Bethrey House

This inspection was carried out on 6th 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

Bethrey House 05/08/08

Bethrey House 08/08/07

Bethrey House 19/10/06

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 6th 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 Bethrey House DS0000020882.V329605.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.V329605.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.V329605.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) 19th October 2006 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.V329605.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 second of key inspections for 2006/07 and took place over five hours on Tuesday 6th February 2007. It was conducted by two Commission for Social Care Inspection regulation inspectors. An unannounced random inspection was carried out on 1st December 2006 as part of the monitoring process for ensuring compliance with the regulations. Twenty six of the thirty eight National Minimum Standards for Older People were inspected. Fourteen people are currently living at the home. 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 and area manager visited the home during the inspection. Four case files were selected for case tracking, relevant documents were inspected, and discussions were held with service users, visitors and members of staff. Many of the service users did not wish or were unable to comment about life at the home the comments of those people who did are included in this report. Observation was made of the various daily activities and a tour of the premises was conducted. Staff on behalf of service users completed five on site survey cards. What the service does well: What has improved since the last inspection? The care plans have all been reviewed and revised with additional documentation for recording and monitoring the care provided. However further development of the care plans is required to ensure that staff are provided with the full details of the health, personal and social care needs of each individual. Improvements have been made to the storage of medication with additional cupboards and a fridge being purchased. The social, recreational and leisure activity programme is being developed appropriate to the service users group. The complaint procedure has been reviewed and improvements made to the recording of any complaints/concerns. Bethrey House DS0000020882.V329605.R01.S.doc Version 5.2 Page 6 The multi agency protection of vulnerable adults procedures have been obtained and will be available shortly for staff reference if required. The corridor on the first floor has been redecorated. Vacant engaged indicators have been fitted to all bathroom and toilet doors. Floor coverings have been replaced in the laundry and bathroom. Suitable hand washing equipment is now available in all areas. The training and development needs for staff have been identified. Arrangements have been made for the home to be heated sufficiently in all areas offering service users the opportunity to use all parts of the home. 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. Bethrey House DS0000020882.V329605.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.V329605.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): OP 1, 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre admission assessments are carried out to ensure that the home can meet the needs of the individuals moving into Bethrey House. The information on the service has recently been reviewed and is readily available; this offers prospective service users and representatives clear information to enable them to decide whether the home will be suitable for their needs. EVIDENCE: The statement of purpose and service user guide have both reviewed in January 2007, and are readily available upon request. A visitor at the home confirmed that he had been supplied with copies of the documents. Four case files were selected for case tracking, all included pre admission information and assessments from the local authorities and social services departments. The case file of the person most recently admitted included an assessment undertaken by the manager of the home and contained good information as to the health and personal care needs this person required. Bethrey House DS0000020882.V329605.R01.S.doc Version 5.2 Page 9 The file of a person receiving regular respite care services had not been updated to include the most recent date of admission. The home does not offer an intermediate care service. Bethrey House DS0000020882.V329605.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): OP 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each service user has a care plan. The plan in most cases includes the basic information necessary to plan the individuals care, some omissions of recording information has the potential for not fully meeting a persons needs. EVIDENCE: Four case files were selected for inspection, all files have been reorganised with additional documentation for recording care needs, assessments and monitoring or an individual’s health and welfare. An initial assessment is made in areas of personal care, health care, mental health, continence, nutrition, daily living activities including mobility and sleeping. Specific care plans are then developed where the assessment identifies a need, concern or problem. The care plan documentation is based on the problem and goal, with the signature of the reviewer and the date of the next review. Improvements have been made to the content of the care plans, however further developments are now required to ensure that staff have all the Bethrey House DS0000020882.V329605.R01.S.doc Version 5.2 Page 11 relevant details of the action they need to take to ensure the health, personal and social care needs are fully met. For example the care plan of one person indicated that they are ‘self caring’, Recording in the daily report made by the care staff indicated that deterioration in physical health had been noted. The care plan was not reviewed or amended to ensure that staff assist with maintaining levels of personal care and that assistance is now required. During the morning of the inspection two care staff supported this person with personal care. Another care plan identified difficulties with a medical condition that required active treatment from the staff to maintain optimum levels of health. Although this condition was mentioned in the care plan a specific plan had not been developed giving staff the information of how to monitor the condition or what to do in the case of an emergency. The daily reports in the case file indicated the increased incidences of a person falling resulting in a hospital admission. The falls risk assessment had been completed by the staff but did not reflect the current difficulties being experienced with falling and did not instruct staff as to what measures need to be taken to reduce the risk of injury. Only one care plan had evidence that the service user had been involved with the care planning process, however it is acknowledged that many of the current service users would not wish to or are unable to contribute to the process. The district nurse visited during the morning and stated she finds the staff helpful and organised and will support the nurse with assisting service users to their bedrooms to receive the treatments in private. The home operates a twenty eight day prescribing system for the administration of medication using a nomad package type with the additional use of boxes and bottles of medication. The monthly supplies of medication are recorded on the Medication Administration Record with the quantity and date of receipt. Any changes and/or additions to the prescribed medication occurring during the month are not being countersigned for checking the accuracy when transcribing the information. A dedicated fridge for the cold storage of medication has been purchased and is in use with the minimum and maximum readings of the temperature being recorded daily. Improvements were noted for the storage of medication, a dedicated lockable cupboard has been purchased and in use. The medication trolley is locked and chained to the wall when not in use. Observations of the medication round were satisfactory with the staff member administering the medications to the individual service users. The staff demonstrated a good knowledge of the procedures and gave a good account of the systems in place for the receipt, storage, administration and disposal of medications. The Medication Administration Record appeared to be correctly completed at the time of the administration. Staff confirm that currently there are no controlled drugs prescribed for any service user. Bethrey House DS0000020882.V329605.R01.S.doc Version 5.2 Page 12 The Medication Administration Record charts do not have a photograph of each individual for the correct identification of each person and to reduce the risk of errors. This was discussed with the manager and area manager, who advised that a digital camera has recently been purchased for this purpose. The care staff were observed to be assisting service users with personal care and interventions discreetly and in a manner which promotes a persons dignity. Staff, service users and visitors were observed to be interacting well all appeared to be at ease with one another. Bethrey House DS0000020882.V329605.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): OP 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are aware of the need to plan the routines and activities of the home in a way that meets the choice and wishes of service users but also tries to be flexible and attempts to provide a service that is focused on the individual needs of the people in residence. EVIDENCE: The manager explained that a social activities programme is being developed ‘appropriate to service user group’, to include reminiscence, arts and crafts and exercise sessions. Posters detailing the arranged activities for the month are displayed on the notice board at the entrance of the home. During the morning service users were observed to be participating in a game of skittles, and connect four, the TV was on in the main lounge. The activities are being recorded on a weekly chart to show the type of activity and the participants, a specific plan of care for social and leisure preferences has not been developed for each individual. This was discussed with the manager and area manager at the time of the inspection. Bethrey House DS0000020882.V329605.R01.S.doc Version 5.2 Page 14 Many frail people with cognitive difficulties are residing in the home and it is acknowledged that they may not wish to or are unable to participate in any structured recreation, never the less the proposed and developing plans for increasing the activities may benefit and enhance the daily living of individuals. One person commented ‘ no one to talk to so just watch and listen but find there is enough to do’ and went on to say that they are satisfied with the level of activities and will join in when they feel like it. Evening local newspapers are available each day. The statement of purpose details the arrangements for visiting the home and for maintaining the links with family and friends. One visitor stated that he and other family members visit the home often and can see their relative in private if they so wish. During the tour of the premises many of the bedrooms were individualised with personal possessions. Staff were observed to be offering service users choices and preferences as to the activities of the day in an appropriate way, very much dependent on the capabilities and capacity of each individual. The dining tables were prepared for lunch with some people being encouraged to sit at the table, the more frail people had lunch in the lounge area and were assisted and encouraged to eat by the care staff. The inspector was invited to have lunch with service users. The meal was nicely presented and at an acceptable temperature; there was a choice of two main courses and desserts. Staff were observed to be reminding people of the choice of menu and serving the preferred option. Service users appeared to enjoy the meal; two people stated that the meals were always good. One person felt the meals had improved and the food was ‘ok’. One person indicated on the on site survey that in their opinion meals ‘have got better’ but another person thought ‘ the meals need to be more tastier’. Bethrey House DS0000020882.V329605.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): OP 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that generally meets the national minimum standards and regulations and is detailed in the statement of purpose and service user guide. The policies and procedures regarding protection of service users are being developed in line with the regulations and other external guidance to ensure staff have an understanding of the protection of vulnerable adults. EVIDENCE: A complaints file is being used to record complaints/concerns; no further complaints have been raised since the last inspection in December 2006. The statement of purpose and service user guide both contain the details of the complaints procedures and a copy is displayed in the entrance to the home. One person stated that if they had any concerns they would talk with a staff member. A copy of the recently reviewed multi disciplinary adult protection procedures has been received from the adult protection coordinator. The manager stated that all staff would be asked to read the procedure and sign to say that they have read and understood them. Further training in the protection of vulnerable adults is being arranged. Bethrey House DS0000020882.V329605.R01.S.doc Version 5.2 Page 16 A lockable safe has been installed in the office for the safe keeping of service users monies and valuables. Two people have been nominated to have the number combinations and access to the safe. Individual accounting records are maintained for each transaction with the service users signature being obtained whenever possible. Bethrey House DS0000020882.V329605.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. JUDGEMENT – we looked at outcomes for the following standard(s): Op 19,21,22,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service provides a homely environment and will benefit from the planned redecoration and refurbishment. There are one or two areas that pose a potential risk to service users and staff for example, the procedures for dealing and disposing of waste and water may be very hot coming from a tap due to a lack of a safety valve. EVIDENCE: A maintenance plan has been developed for 2006/07 and includes the replacement of fabric and fittings together with redecoration of the communal and private rooms. Time scales for the work to be carried out during the year have been identified and appear to be on target. Bethrey House DS0000020882.V329605.R01.S.doc Version 5.2 Page 18 The local fire officer last visited the premises in March 2006 confirming compliance with the recommendations made for improving the fire safety aspects within the home. Warning signs have been placed on the patio doors leading to the conservatory, this reduces the risk of someone bumping into the doors when they are closed. The quiet lounge on the first floor is used for meetings, reviews and is available for service users and their visitors to use should they wish to do so. The manager explained that assessments have been carried out for the use of bedrails and protective bumpers, following these assessments all bed rails assessed as not being necessary or required have been removed. New flooring has been installed in the laundry and alginate bags are now available and in use for dealing with soiled linen. The corridor on the first floor has been fully redecorated, vacant/engaged indicators have been placed on all toilet and bathroom doors and no wedges were observed to be in use. To reduce the risk of the spread of infection and for general hygiene purposes paper towels, liquid soap and lidded disposal bins have been installed in all communal toilet and bathrooms and in private bedrooms. It is still recommended that an automatic sluice disinfector be available for the safe and effective use for dealing with bodily waste. The shower in the shower room has a preset function for the control of the hot water, the manager confirmed that this has been set at close to 43 degrees Celsius, the extractor fan was working. The area would benefit from redecoration to make it a more conducive and pleasant area for service users to use. The hot water outlets in areas accessible to service users are being tested on a regular basis to ensure a safe temperature is maintained. The wash hand basin in the office recorded a temperature of 60 degrees Celsius. To enable effective hand washing procedures for staff it is recommended that a fail-safe valve be fitted to maintain the temperature at a safe level. During the tour of the premises the bedrooms were warm, the manager confirmed that the heating is no longer turned off in these areas during the day. A person completing the on site survey indicated that during the past six months the presentation and decoration has improved. Bethrey House DS0000020882.V329605.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are generally satisfied that the care they receive meet their needs and care staffing numbers are generally maintained at sufficient levels. The service recognises the importance of training, but there are still some areas that need attention in relation to the core and specialist topic areas. EVIDENCE: A rota is maintained to show which staff are on duty at any given time of the day or night. At the time of the inspection three care staff were on the premises together with additional ancillary staff. The manager was on the premises and confirms that she is allocated 100 supernumery time. The area manager discussed the possibility of the recruitment of more care staff following the recent change to the category of registration to provide a service for up to seven people with dementia. Domestic and catering tasks are being attended to by care staff in addition to their usual care duties during the evenings and at weekends. Additional staff should be available for these duties; this was discussed with the manager and area manager at the time of the inspection. Two staff personnel files were selected for inspection, both files did not contain the required number of references, a revised system of evidencing that Bethrey House DS0000020882.V329605.R01.S.doc Version 5.2 Page 20 criminal record bureau disclosures checks have been carried out is being developed by the area manager. Certificates and records of achievement are retained to evidence the training undertaken by each individual, however the dates on the certificates for moving and handling (08/01/04), fire safety (29/07/03), Health and safety (08/03/03) evidence that training in theses core topics are way out of date. One file did not contain any training for fire safety or first aid. The area manager stated that five staff have accreditation at National Vocational Qualification level 2, some are working towards level 3 in care and confirms that other staff members will be enrolled on courses in March 2007. Regular formal supervision has been arranged for care staff, procedures must now be adopted to continue the regular meetings at least six times a year. The training and development requirements for staff have been identified; the area manager stated that training opportunities will be available for staff throughout the year. Service users and visitors commented positively on all levels of staff ‘ excellent staff’, ‘very good’, ‘ can’t complain’. Bethrey House DS0000020882.V329605.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager and area manager are aware of and work to the basic processes set out in the national minimum standards. The staff team appears to be user focused, and generally works in partnership with family of service users and professionals. The manager and area manager has developed systems that monitor practice and compliance with the homes plans, policies and procedures. Both are aware of the areas where they need to make improvements and have an action plan for undertaking the work. EVIDENCE: The current registered manager continues to work towards accreditation on the Registered Managers Award; the proposed completion date for the end of Bethrey House DS0000020882.V329605.R01.S.doc Version 5.2 Page 22 2006 was not achieved due to unforeseen circumstances. A revised date for completion on the course has been agreed of 31st March 2007. Staff and service users monthly meetings have been arranged with dates allocated during the month. Quality assurance and monitoring systems continue with satisfaction questionnaire being distributed, these are audited at another care home within the company. Improvements have been made to the procedures for the safe keeping of service users personal monies and valuables. A lockable safe has been installed in the office and two people have been nominated to have the number combinations and access to the safe. Individual accounting records are maintained for each transaction with the service users signature being obtained whenever possible. Routine weekly and monthly safety checks are being carried out and records kept in relation to the fire alarm, emergency lighting, and water temperatures. It was not possible to establish the exact date of the latest portable appliance testing. The records could not be found. Risk assessments have been carried out for safe working practice topics with the findings recorded. Records were not available to ensure that staff have had training and guidance for the staff working practices in moving and handling, fire safety, first aid, food hygiene and infection control. Bethrey House DS0000020882.V329605.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 3 X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Bethrey House DS0000020882.V329605.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15(1) Requirement Timescale for action 30/03/07 2 OP8 12(1)(a) (b) 3 OP9 13(2) 4 OP9 13(2) 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 Previous requirement 30/11/06 and 31/01/07 Not fully met The registered person must 30/03/07 ensure that all assessments (Nutritional screening, tissue viability, continence and risk of falls) the findings recorded and where necessary linked to specific plan of care. The registered person must 30/03/07 ensure that all handwritten instructions on the Medication Administration Record charts mirror the prescribing instructions and signed by two people. The registered person must 30/03/07 ensure that for identification purpose and to reduce the risk of errors a photograph of each service users must be with the Medication Administration Record DS0000020882.V329605.R01.S.doc Version 5.2 Bethrey House Page 25 5 OP25 13(4) 6. OP26 13(3) The registered person must 30/03/07 ensure that to reduce the risk of scalding preset valves of a type unaffected by changes in the water pressure are fitted to maintain a temperature of close to 43 degrees C The registered person must 30/03/07 ensure systems and procedures are in place for effective and hygienic disposal of bodily waste. The registered person must ensure that domestic and catering staff are employed in sufficient numbers at all times. The registered person must ensure that a minimum ratio of 50 of care staff are trained to National Vocational Qualification Level 2 or equivalent Previous requirement 31/01/07 Not met The registered person must ensure two written references are obtained and kept on file prior to a person starring work at the home. 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 Previous requirement 30/11/06 and 31/01/07 met The registered person must ensure that the registered manager completes the National Vocational Qualification level 4 in care and management. Previous requirement 31/01/07 Not met The registered person must ensure that staff are instructed in all safe working topics to include moving and handling, fire safety, first aid, food hygiene and infection control. DS0000020882.V329605.R01.S.doc 7 OP27 18(1)(a) 30/03/07 8. OP28 18(1) 30/03/07 9 OP29 19(4) Schedule 2(5) 18(1) 30/03/07 10 OP30 30/03/07 11. OP31 9(2) 30/03/07 12 OP38 18(1) 30/03/07 Bethrey House Version 5.2 Page 26 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 OP21 OP26 Good Practice Recommendations It is strongly recommended that consideration be given to the complete refurbishment of the shower room. 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. Bethrey House DS0000020882.V329605.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Bethrey House DS0000020882.V329605.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. 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!