Inspection on 15/08/06 for Bierley Court

This inspection was carried out on 15th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bierley Court 16/06/08

Bierley Court 10/07/07

Bierley Court 28/10/05

Bierley Court 06/05/05

Bierley Court 03/11/04

Bierley Court 03/06/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Bierley Court 49 Bierley Lane Dudley Hill Bradford BD4 6AD Lead Inspector Karen Westhead Key Unannounced Inspection 15th August 2006 09:30a 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 Bierley Court DS0000034010.V306034.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. Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bierley Court Address 49 Bierley Lane Dudley Hill Bradford BD4 6AD 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) 01274 680300 01274 680303 bierleycourt@schealthcare.co.uk Southern Cross Healthcare (Kent) Ltd Ms Frances White Care Home 40 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (5), of places Physical disability over 65 years of age (25) Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th October 2005 Brief Description of the Service: Bierley Court was designed as a care home and provides a service for older people. There is level access, a passenger lift and a secure garden. There are a variety of communal rooms, assisted bathrooms and communal toilets to both floors. The bedrooms are single and all are provided with an en-suite toilet. Bierley Court is situated three miles from Bradford city centre. Public transport can be accessed close by and parking is provided within the grounds. The home is registered to provide care for up to forty residents. Within that total twenty-five residents may have a physical disability and ten can have a diagnosis of dementia. The minimum fee is currently £308.14 rising to £388.00 depending on circumstances. Additional charges are made for hairdressing and any newspapers and magazines, which are not provided by the home. A pre-inspection questionnaire was sent out to the home prior to the visit. This was subsequently returned and provided up to date information about the home; records and procedures; staff and residents. Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between 1st April 2006 and 1st July 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All of the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by residents. On occasions it may be necessary to carry out additional site visits, some visits may focus on a specific area and are known as random inspections. The visit was unannounced and was carried out by one inspector. The inspector arrived at 9.30am and feedback was given at the close of the visit at 5pm. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at the completed preinspection questionnaire, the number of reported incidents and accidents, the action plan submitted following the previous inspection and reports from other agencies such as the fire safety officer’s report. This information was used to plan the inspection visit. A number of documents were inspected during the visit; some areas of the home were seen, such as bedrooms and communal areas. The inspector also spent a good proportion of her time talking to residents, staff and visitors. Residents who were unable to comment on their experiences were observed. CSCI comment cards and post-paid envelopes were left, to be distributed to residents and their relatives. One comment card asks questions about the inspection process and the way the inspectors carried out their duties. After completion these are returned to the CSCI. At the time of writing this report five responses had been received from visitors and four from residents. Their views are contained throughout this report. Overall, visitors were satisfied with the care provided and residents’ responses were also positive. One visitor said their relative ‘is happy here and we couldn’t wish for more care and support than she is already receiving.’ Another comment was ‘all the staff are very obliging to residents and their families.’ Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 7 Some staff said they had not received formal training around adult protection. None of the staff had been given training around one specific area of care, which affected one of the residents in the home. Staffing levels did fall below the minimum required, on some occasions. Some cleaning issues were noted in the kitchen area. Fire doors are not kept shut, but are held open through resident choice, thus compromising fire safety procedures. Staff take part in fire drills, their names are included in the fire register. The sluice was out of order. Staff confirmed this was not used presently and was therefore not required. This should be kept under review. Recruitment and selection processes do not safeguard residents. 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. Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 8 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 Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 9 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): 1, 3, 5. Standard 6 is not applicable. Prospective residents have sufficient information to help them make an informed choice about Bierley Court. No one moves in without having had his or her needs assessed. All admissions are subject to a trial period and review process. EVIDENCE: Twelve care plans were examined. These included the most recently admitted resident and those files chosen at random by the inspector. Residents who had lived at the home longer than twelve months did not have a full preadmission assessment, however more recently admitted residents had been taken through a more thorough assessment process. All files contained an up to date care plan. Some of the residents spoken to had lived at Bierley Court for six years. It was clear that staff had put a lot of effort and work into making sure the care plans were up to date and reflected the care needs of each individual. This is an improvement since the last inspection. Every file seen contained the Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 10 necessary risk assessments relating to pressure area care, observations following a fall or any other event which was out of the ordinary and dependency levels. Where residents were able, they had signed their own care plans and consent forms for photographs being taken for identity or medical purposes. One care plan needed to be amended following case tracking and discussion with the staff on duty. This was addressed by the senior on duty. All residents have a statement of terms and conditions. The home provides a wide selection of information relating to the services and facilities provided. Therefore giving a resident an idea of what to expect on admission. Residents are invited to visit the home before being admitted for a trial period. This is determined on an individual basis, according to the circumstances and needs of each resident. It was clear that some trial periods are extended if necessary in order for the resident to be sure about their decision to stay. One visitor said that somebody had visited their relative prior to them being admitted and had made notes about their requirements. They said that they had been to look round before making the decision for their relative to move in and that their questions had been answered and they had taken information away with them. Standard 6 refers to intermediate care. This is not provided at the home. Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 11 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): 7, 8, 9 and 10 Residents and their representatives are included in the completing care plans. Improvements have been made with care plans since the last inspection. Residents were addressed in a respectful and dignified way by staff. Resident’s health care needs are met. The homes policy on medication protects residents from potential errors or fraud. EVIDENCE: Twelve care plans were examined. Some of the residents talked to during the visit said they knew there was a file about them and understood this to include their individual details and what care they needed. Records showed that residents or their relatives had been involved with the writing of the care plan and in some cases residents had been able to sign their own records. Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 12 The care plans showed that forms were in place to carry out healthcare and risk assessments such as: a) Moving and handling b) The risk of developing pressure sores c) Nutritional risk assessments d) Dependency assessments. Where these assessments showed that the resident had particular needs information was included in the care plans. One aspect of a residents care needs had changed following recent events. Staff on duty were able to reflect on the changes and give accurate accounts, however, this had not been clearly shown in the care plan. This was discussed with the senior on duty who was able to address the matter immediately. The discussion demonstrated staff were fully aware of the residents needs and this had been verbally communicated well, however it was necessary for the full details to be documented. Notwithstanding this oversight, the care plans were clear and well written. Staff said that wherever possible residents stayed with their own doctor but if they moved out of the doctor’s area they would have to register with the local surgery. Residents spoken with said they had confidence in the doctors they had seen and that staff were responsive to their needs when they needed medical attention. Staff were not seen giving medication to residents. However, safe procedures were in place. The medication administration records looked at had been properly filled in. Two staff said they had completed a course on medication in recent months. Records showed a further four were part way through their training and three more had been allocated a place on the next course. Five staff have a first aid qualification. Staff were seen knocking on residents’ room doors before entering. Relationships between staff and residents were noted as friendly and respectful. Residents, who were able to give a view, said that staff treated them with respect and dignity and treated them as adults. One relative said staff were obliging. Words such as ‘wonderful, kind and caring’ were used when residents spoke about staff, including the manager. Residents knew who the manager was. Bierley Court DS0000034010.V306034.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): 12, 13, 14 and 15 Resident’s cultural and religious needs are met. The home employs an activity organiser. Social and recreational needs are being met in a variety of ways. This area of care has improved since the last inspection. Residents are given ample opportunities to take refreshments and snacks inbetween scheduled meal times therefore meeting their nutritional needs. Residents are helped to make choices and where appropriate retain control over their lives. EVIDENCE: The home has an equal opportunities policy in place for staff and residents. Resident’s cultural and religious needs were noted in their care plans. Visitors said that they were able to visit at any time and that staff made them feel welcome. They said that they were satisfied with the care given to their relatives and that they thought staff were kind. Food provision is good. The inspector took the opportunity to sample the main meal of the day. A starter, two hot choices and a selection of desserts. The meal was well presented. Residents were given ample time and the Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 14 opportunity to choose what they would like to eat. When talking to the residents after their meal they all said they had enjoyed it. Food and snacks are prepared in a way, which allow residents with difficulties to access them and enjoy them. Examples of this were seen, including specialist crockery and cutlery. The visitors comment cards confirmed: • they were welcomed into the home, • able to visit their relative in private, • were kept informed of important matters affecting their relative, • felt there were sufficient staff on duty, • they were satisfied with the overall care provided. • Not everyone was aware of the complaints procedure. The questionnaires from residents confirmed: • they had a contract (statement of terms and conditions), • had been given enough information about the home before moving in, • they always or sometimes received the care and support needed, • staff always or usually listened and acted on what they said, • staff were always or usually available when needed, • they always received medical support when required, • that there were always activities they could take part in, • that they always or usually liked the meals, • that they always knew who to speak to if they were not happy, • the home was always fresh and clean. None of the residents, filling out the questionnaire, wished to speak further to an inspector. It is highly likely that the residents who completed them did also speak to the inspector on the day of the inspection. Bierley Court DS0000034010.V306034.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): 16 and 18 Complaints are taken seriously and dealt with appropriately. Some staff said they had not received training around adult protection therefore it is not clear that residents would be protected from abuse. Financial arrangements are well organised and should safeguard the personal monies belonging to residents. EVIDENCE: The home has a comprehensive complaints procedure. This is made available with the Statement of Purpose. One visitor, who completed the comment card, said they were not aware of it. However, none of them had made a complaint. Those spoken to on the day said they knew who to talk to if they had a concern or problem. There had been three complaints since the last inspection. All these had been dealt with by the home and not referred to the CSCI. These were all dealt with using the homes complaints procedure and within 28 days. Following one complaint a member of staff involved was referred to POVA, a register which keeps a record of those involved in incidents, which affect the health and welfare of vulnerable adults. Some staff said they had not received training about adult protection. They said they would not hesitate to report concerns to the person in charge. However, this was reliant on their instinct rather than formal training. Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 16 Financial arrangements are well organised with procedures in place to ensure all transactions are recorded and audited. The home employs an administrator who spent time showing the inspector the systems in place. One cash balance was not consistent with the record kept. This was identified and rectified by the administrator. This had been an oversight and would have been picked up when the cash held was consolidated. Residents have access to their personal monies as required. The administrator confirmed that twelve of the residents are subject to Power of Attorney and three are under Guardianship. Residents who have savings have the assistance of a third party. Bierley Court DS0000034010.V306034.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): 19, 21 and 26 The rolling programme of maintenance and redecoration continues and the home is benefiting from the improvements. The home was clean and tidy and meets the needs of the residents. Some cleaning issues were noted in the kitchen area. Fire doors are not kept shut, but are held open through resident choice, thus compromising fire safety procedures. EVIDENCE: All laundry is dealt with in house. Residents said they were happy with the way their clothes were being washed and dried and that they had not suffered any losses. All the linen seen during the visit was well presented and cupboards were well stocked. Despite a laundry assistant being on authorised leave, staff were managing to cover the shortfall. A programme of maintenance, cleaning and redecoration is in place. The home employs a team of staff to undertake these specific jobs. Since the last inspection the reception area, lounges, bedrooms and toilets had been Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 18 redecorated. The gardens are being redesigned and as part of this a number of plants and shrubs had been planted. The idea for relatives to sponsor a rose bush had been successful. Residents can sit out at tables in the garden, which has been made more secure with extra fencing and gates. Whilst talking to residents in their bedrooms and communal areas the inspector noted the cleanliness to be very good. However, the hot food trolley, in the kitchen, was soiled with dried food and spillages and was in need of a deep clean. Attention is also required to ensure the floor covering in this area is kept intact for hygiene and cleaning purposes. Notwithstanding this the team of ancillary staff clearly take a pride in their work. Residents had been encouraged to bring any cherished items with them and many of the bedrooms had been personalised. There are two bathrooms on each floor. Of these only two have hoists fitted. The staff said that the two unassisted bathrooms were rarely used, as the residents living at Bierley Court were unable to step in or out of the bath with ease. This resulted in fewer residents being able to choose to have a bath at any particular time. The provision of bathing needs to be reviewed. To make sure there is an adequate number of bathrooms to meet the needs of the residents accommodated. A nurse call system is available to residents. This was tested twice by the inspector, and responses were good. Staff attending cancelled the bell at source. There were no comments from residents to suggest there is a delay in staff attendance if they summon help. A number of bedroom doors were propped open with a variety of objects, including chairs, footstools and rolled up newspapers. Whilst it is acknowledged that some residents, who chose to spend time in their rooms, want their doors keeping open. This does compromise fire safety. There needs to be a review of this practice and where required the necessary equipment provided. Staff take part in fire drills. Their names are included in the fire register. The sluice was out of order. Staff confirmed this was not used presently and was therefore not required. This should be kept under review. Bierley Court DS0000034010.V306034.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Staffing levels did fall below the minimum required on some occasions. Not all staff have received appropriate training in some areas and there is a risk that residents needs will not be met. Recruitment and selection processes do not safeguard residents. Staff were described in positive terms by visitors and residents. EVIDENCE: Many of the staff were part way through courses, including National Vocational Qualifications; Nutrition and Health and other mandatory training. Staff spoken with felt the training was useful and allowed them time to reflect on care practices and enhance their skills. One resident has a specific care need (identified), which requires daily attention. None of the staff had received training and those who were able to address the need did so from skills brought with them from other homes. It is imperative that all staff have been given relevant up to date training. When staff were asked what could make the home better, they said that making sure the home was fully staffed on every shift would make the experience of living in the home better for residents. Despite some shifts having been covered by agency staff, it was evident that staffing levels do fall below the minimum number. In the last two months, eight shifts had been covered by agency staff. The registered person must make sure that staffing Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 20 levels are appropriate to the physical, social and psychological needs of residents living in the home. Notwithstanding this important point, the established staff team were described in positive terms by both residents and visitors. The inspector gained the impression that staff worked as a team and that they were committed to their roles. A district nurse and other care professionals were visiting residents during the inspection. They were treated in a professional and courteous manner by the staff on duty and commented on the positive atmosphere in the home. Three staff files were seen. These included those who had recently been employed or had been highlighted as not having a record bureau (CRB) check on the staff list. Only one of the three files contained an appropriate CRB. The remaining files included a POVA 1st check, although one could not be confirmed as the person identified has had several different addresses and name changes. One file had an application form, which had sufficient detail and interview notes. The other application forms were sparsely filled in and did not give a full employment history. One CV provided did not match the employment history contained on the application form. The references seen for one worker did not match the details provided on the application form, and one reference bore no relation to the job applied for. It is of concern that the correct information had not been sought prior to staff being employed. The registered person must make sure these issues are addressed and safeguards put in place until they can be satisfied as to the suitability of employees. Bierley Court DS0000034010.V306034.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 An appropriate management structure is in place making sure staff receive guidance and support in their delivery of care. Quality assurance systems are in place giving users of the service an opportunity to voice their views and initiate improvements in the delivery of care. The financial arrangements safeguard the interests of residents. Overall, safe working practices were observed during the visit. EVIDENCE: The registered provider has issued new quality assurance systems, which include new audit tools to be used in the home. The manager was on annual leave at the time of the visit; therefore this area will be further discussed at the next inspection. Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 22 Since the last inspection the manager has been through the registration process and now registered with the CSCI. Staff said morale was good and that they felt supported by the manager and the organisation. The home is registered to look after ten adults, who are suffering from dementia, within the numbers registered. It was evident that the home is currently accommodating more that that, maybe as many as nineteen. This must be explored and if found to be correct the registered provider must review the current registration categories and if necessary apply to vary their registration. This issue is also of significance when the staffing levels are not being maintained for ten residents suffering from dementia. Therefore an increase in residents needing a higher level of support must also impact on the staffing levels. Bierley Court DS0000034010.V306034.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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 2 X 3 X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP18 Regulation 12(1)(b) and 13 Requirement The registered provider must make sure all staff have been trained to be able to identify and take action if they suspect or witness any form of adult abuse. The registered provider must make sure the premises are maintained appropriately and are fit for purpose. Including the provision for fire safety. The registered provider must make sure the equipment and floor covering in the kitchen is kept clean and serviceable. The floor covering must be sealed to allow for proper cleaning. The registered person must make sure there are sufficient staff on duty at all times. The registered person must make sure the people employed in the home have been through a robust recruitment process, including the necessary checks required to make sure they are suitable to work with vulnerable adults. The registered person must make sure that all staff have DS0000034010.V306034.R01.S.doc Timescale for action 29/10/06 2. OP19 23(4) 20/11/06 3. OP26 16 and 23 25/09/06 4. 5. OP27 OP29 18(1)(a) 19 14/09/06 14/09/06 6. OP30 18(c) 29/10/06 Bierley Court Version 5.2 Page 25 received the necessary training to deal with any specific needs of residents. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bierley Court DS0000034010.V306034.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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