Inspection on 18/10/05 for Birch Lawn Resource Centre

This inspection was carried out on 18th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Birch Lawn Resource Centre 26/09/07

Birch Lawn Resource Centre 25/01/07

Birch Lawn Resource Centre 10/05/05

Birch Lawn Resource Centre 18/11/04

Birch Lawn Resource Centre 08/06/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Birch Lawn Resource Centre Sullivan Road Sholing Southampton Hampshire SO19 0HS Lead Inspector Christine Hemmens Unannounced Inspection 18th October 2005 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 Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 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. Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Birch Lawn Resource Centre Address Sullivan Road Sholing Southampton Hampshire SO19 0HS 023 8044 5906 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) Southampton City Council Pauline Holloway Care Home 29 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (33), of places Physical disability (6), Physical disability over 65 years of age (6) Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. A maximum of six service users in the category DE(E) may be accommodated at any one time. A total of six service users in the categories PD and PD(E) may be accommodated at any one time. Service users admitted in the categories PD and PD(E) may only be accommodated in the designated Rehabilitation Unit. Service users in the category PD may only be accommodated between the ages of 55 years and 64 years. 10th May 2005 Date of last inspection Brief Description of the Service: Birch Lawn is a purpose-built property providing care and support to 27 6 rehabilitation persons of either sex over the age of 65 years and who are frail or have a physical disability. The home is the responsibility of Southampton City Council and Mrs P Holloway is the registered manager for Birch Lawn. The home is situated in Sholing, a residential suburb in the South East of Southampton. It stands on a three-acre site of well laid-out lawns, with shrubs and trees. There is a raised garden, greenhouse and vegetable plot providing opportunities for service users to maintain an interest in gardening. Garden furniture on the patio area enables all service users to enjoy the garden, particularly in the warmer months. The building has two floors with a passenger lift to the first floor. The interior to the building has been pleasantly decorated and appropriately furnished with good quality furnishings. The home has its own shop, hairdressing room, library and bar. A separate Intermediate Care Unit (managed by Birch Lawn) offers residential rehabilitation for six persons who are 65 years of age or over. Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced visit to the home this year. The purpose of the visit was to review requirements issued following the last visit to the home in May 2005. The registered manager Mrs P Holloway assisted the inspector with the inspection, the inspector spoke with a small number of residents and staff. The manager has recently been supporting an acting manager in another Southampton City Council Home to improve its standards, however as reflected in the body of the report this has impacted on the delivery and quality of service provided at Birch Lawn. As a result of this visit to the home it has been issued with sixteen requirements and one recommendation. This demonstrates that the home’s standards are dropping as previous visits to home had limited requirements made. Of the seventeen requirements made four have been repeated resulting in a serious concern letter going to responsible individual and an immediate requirement was made in respect of staff starting employment without all the appropriate employment checks. What the service does well: The home does well to provide an individualised approach to the health and social care needs of the residents by undertaking a thorough assessment process to establish if the home can meet the prospective resident’s needs. The residents with whom the inspector met with said they were happy with the care and support they received and felt the staff and the manager to be very kind and caring. The inspector observed a happy, relaxed and welcoming home. Staff are observed to adopt a respectful and gentle approach to the residents and visitors to the home. Gentle banter between staff, residents and the manager was seen on several occasions and one resident informed the inspector “we have a bit of a laugh here”. The home provides well-balanced and wholesome foods, catering for special dietary requirements and providing alternatives when requested. The inspector was informed “The food’s very good here”. The home in general provides a warm welcoming and comfortable environment for residents to live in with appropriate facilities and adaptations to meet their needs. Residents have their own rooms, which are kept clean and tidy and have been personalised with residents’ belongings. Mrs Holloway is a skilled and competent manager, who is open, honest and who has developed an environment for residents and staff to work and live in Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 6 that is supportive and inclusive. However this has had its downfalls as identified in the body of the report and in “What they could do better” some of the standards in the home have fallen as the manager has assisted in developing another service. What has improved since the last inspection? 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. Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 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 Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 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): 3 and 6 The home has established good procedures in assessing and obtaining information on prospective residents to the home. The home’s six rehabilitation beds are transferring to another local authority home. EVIDENCE: The manager supports her senior care coordinators to undertake a thorough assessment on all prospective residents to the home. The inspector spoke with two senior carers who confidently described the assessment process. The home will first receive a referral and obtain specific information from the placing authority in order to make an initial judgement if the home can meet their needs. The prospective resident is then invited to the home for a day assessment to observe how much support they will need in terms of personal care, mobility, their health, welfare and social needs. The assessment documentation from the placing authority and the home’s own assessment documentation forms the basis of the residents’ care plans. Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 9 At the time of the visit the inspector was informed of the intentions of the Local Authority to move the six rehabilitation beds to another service within Southampton City Council. Application to change the certificate of registration to registered the home for thirty-three beds has been made. Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 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): 7 and 9 Generally the homes care plans reflect the needs of the residents, however further improvement is required to regularly review, update and ensure they describe “how” the support is to be carried out. The home must make improvements to its medication administration procedures. EVIDENCE: Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 11 Residents each have an individual plan that has been developed using a person centred approach. The plans address some of their needs identified in the assessment process, including their social and emotional needs. However since the previous visit to the home the inspector found that the quality of the care plans, the review process and details on “how” the residents’ care must be carried out has fallen below standard. The inspector viewed two residents’ plans, tracking one resident who had recently been admitted to the home and another who has specific dietary requirements. The residents’ personal plans did not reflect their changing needs or the specific support required, this could potentially place the residents at risk of harm by not having their specific care needs carried out appropriately and consistently. The manager is advised to regularly quality audit the care plans and ensure they truly reflect the needs of the residents. The inspector spoke with a small number of residents who informed the inspector that they felt very well cared for and that staff were always very kind and helpful. The home supports residents with their medication, medication is stored safely and administered by staff that have received training. The manager informed the inspector that the home is changing its dispensing pharmacist to a reputable high street pharmacy that will provide a comprehensive contract to the home to ensure medications are received, administered, stored and returned safely and efficiently. The manager informed the inspector that the home will be provided with further training in using the new system. The inspector was informed that in addition to providing an efficient service the contracting pharmacy will regularly audit the homes medication procedures. This is seen as good practice. However on the day of the visit to the home the inspector found discrepancies in the administration of medication, such as staff signature gaps in medication administration recording sheets and no explanation for the reason for omission of medication. The manager must undertake regular audits of the medication and take appropriate action to deal with discrepancies. The manager must ensure that residents who receive “as required” medications (PRN) have clear support plans in place to guide staff. The manager is advised to delegate a member of staff to regularly clean the medication cupboard and audit stock. Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 12 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): 15 The home appropriately meets the dietary needs of the residents, however it must ensure the home can adequately monitor specific dietary requirements. EVIDENCE: The home provides wholesome and appetising meals for the residents. The home has designated catering staff who prepare and cook the meals on site. The cook informed the inspector that she meets with new residents to identify their specific likes and dislikes and to establish if there are any specific dietary requirements. Residents are provided with three meals a day and regular drink, beverages and snacks are available. One resident informed the inspector that the food was very enjoyable and he could have an alternative if he didn’t like what was on the menu. The menu is written in large print and displayed in the main thoroughfare of the home for all to see. Residents can eat their meals where they wish, however the manager informed the inspector that they try to encourage residents to eat together in the main dining room in order to socially interact and provide stimulation for one another. The large dining room is nicely decorated, clean, and comfortable and dining tables are nicely laid with napkins, condiments and flowers. The home caters for residents who have specific dietary requirements such as diabetes, and liquid diets etc. The manager informed the inspector that staff Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 13 have received specific training in monitoring the needs of residents with specific dietary requirements, however the inspector discovered that the home was not fully meeting the dietary requirements for one resident as instructed by the dietician as the weighing scales were broken. Therefore the resident is being placed at potential risk of falling into ill health by not having his specific dietary needs fully monitored. The manager therefore must ensure required equipment is kept in good repair at all times and staff are aware of the importance of regular monitoring. Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 14 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 The home takes seriously complaints and responds efficiently to any concerns raised by residents or residents’ representatives. However the home must ensure that information provided to residents is up to date and available at all times. Safeguarding residents against harm of abuse has been addressed in Standard 29 recruitment. EVIDENCE: The home has developed clear policies and procedures for dealing and responding to complaints. Residents and their representatives are issued with a complaints procedure on entry to the home, describing how and who to make a complaint to. The manager keeps a record of all complaints, the nature of the complaint and how it was resolved. This is seen as good practice. However it remains a concern that the complaint booklets seen in residents’ bedrooms are the old complaints booklets that do not give the correct name of the regulatory body. The manager confirmed that the home had received new information booklets and it was her understanding that these had been placed in all residents rooms, however out of the ten bedrooms seen by the inspector only one room had the correct information. The manager explained that she recently hadn’t had time to quality audit the home and information provided to residents, as she had been very busy supporting another home within the service. This unsatisfactory as the manager must ensure standards are maintained at all times in the home. Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 15 The inspector spoke with a number of residents who said they felt they could talk to the manager and staff if they had any concerns as the manager and her staff are very kind and helpful. Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 25 The home provides a comfortable and clean environment for residents to live in, however the home’s heating and water temperatures require regular monitoring and adjusting to provide a comfortably heated and safe environment to live. The home must ensure all areas of the home are maintained and repairs and promptly responded to. EVIDENCE: Each resident has a room of their own which is comfortably furnished and decorated. Residents can bring in their own small items of furniture at the managers discretion and furnish their room with their personal belongings. All the residents with whom the inspector spoke with said Birch Lawn was a pleasant and comfortable home. The home has had problems with its heating for a number of years, the boiler is identified as the problem. Some areas of the home appear very warm and others cool. The home has purchased additional heaters for some rooms and these have been risked assessed. Following the last visit in May 2005 the Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 17 home was issued with two requirements in respect of the heating. One of the requirements has been repeated for a third time, and the other will be repeated, as it had not been fully complied with. The manager could demonstrate that she has made many requests for work to take place on the boiler to rectify the heating, however Southampton City Council’s Maintenance Department have not responded as efficiently as required. The manager was advised that the concerns regarding the failure to comply with the requirement will be taken up directly with the services responsible individual. However a further failure to comply with the requirement will result in enforcement action. However the manager is responsible for ensuring that the requirement to monitor the heating is complied with. The inspector established that the home has developed a temperature monitoring form to record temperatures in various areas of the home, however there was evidence that the temperatures had not been regularly taken and recorded. This is further evidence to suggest that the manager has not had time to audit quality and standards to ensure they are being adhered to. The manager was informed that she must record temperatures four times a day and send a copy of a weeks recording to the Commission for Social Care Inspection To establish if the home was maintaining a safe environment for the residents to live in the inspector took random hot water temperatures from residents’ bedrooms and found a number of the sinks to exceed the recommended temperature of 43 centigrade. The manager is advised to record hot water temperatures weekly to prevent the risk of scalding. The manager must also ensure that residents identified as at risk from scalding are fully assessed and supported. The inspector also found shoddy workmanship in making good the ceiling in the main entrance following works to the home’s electrics in May 2005. The suspended ceiling tiles were found to be broken leaving holes in the ceiling in places and other tiles had not been replaced properly. The manager informed the inspector that she had asked the workmen to come back and make repairs, however it is unacceptable to leave the ceiling in such away. Not only is the ceiling unsightly the residents have been and continue to remain at potential risk of being hit by falling tiles. The manager must take action to rectify the damage to the ceiling. Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 The home does not adequately safeguard residents from potential risk of harm of abuse, as full-required recruitment checks have not been undertaken on all staff. EVIDENCE: The manager informed the inspector that she was in the process of auditing staff personal files to ensure all checks were in place. The manager had made some progress in auditing the files, however of the five files the inspector viewed only one staff members records were complete of all of the information required under the Care Homes Regulations. One member of staff did not have a record of any checks undertaken on them including a criminal record bureau check (CRB) and a protection of vulnerable adult check (POVA). The manager was immediately required to ensure the member of staff did not have access to residents until such checks are in place. The manager stated she had been supporting an acting manager at another home and was fully aware of what checks were required to be in place, however had not had time herself to audit all of her staff records. The manager is advised that the home she is registered for is her ultimate responsibility and she must ensure her priorities lie with her home. The concerns brought to light in respect of the homes standards dropping because the manger is currently supporting another home will be raised with the responsible individual. Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 19 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): 35 and 38 The home attempts to safeguard residents from risk of financial abuse and as far as feasibly possible safeguard residents from potential environmental risks, however further measures must be put in place to protect residents from the potential risk of fire. EVIDENCE: The home has good policies and procedures for handling residents’ monies, however following a recent spate of attempted fraudulent claims on residents bank accounts the home has had held regular recorded meetings with the residents and met with each one separately to discuss security of personal belongings. Each resident has a lockable cabinet and the resident is advised not to bring valuables into the home. There was evidence that the residents had signed to say they understood the risk of leaving their valuables and money lying around. A meeting to discuss the investigation into the fraudulent claims took place the next day. There was evidence to suggest the home does its best to inform and Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 20 make residents aware of the risks, however the manager should consider introducing further procedures in respect of handling residents cheque and pension books. The inspector viewed the home’s fire records and found areas of concern, especially in respect of the failure to respond to a fire report undertaken by the Hampshire Fire Authority in August 2004. A large number of the reports recommended actions still remain unmet. The home undertakes its own weekly and monthly checks on fire alarm call points and fire extinguishers, however the staff training records indicated that staff had not received and training since January 2005, and the training record did not clearly state what staff had attended. On inspection of the home the inspector was informed that one resident insisted on propping his door open, one of the recommendations in the fire report 2004 recommended that residents bedroom doors should be self closing. The manager is advised that the serious concerns regarding the failure to respond to the report will discussed with the responsible individual, however the manager must: (1) (2) (3) (4) (5) Risk assess the resident wishing to have his door propped open. Undertake fire training for all staff. Record the full name of staff attending training including agency staff. Establish if the homes fire risk assessment must be carried out annually. The registered manager continues to fail to have full access to records held on behalf of the homes environment, e.g. Boiler servicing certificate, record of legionnaires testing. Therefore the manager must make arrangements to have access to service records. Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 21 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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 2 X X X X X 1 X STAFFING Standard No Score 27 X 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 X X 1 Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 22 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(2)(b) Requirement The registered manager must ensure residents care plans are regularly reviewed and updated where required. Timescale for action 28/02/06 2 OP7 15(1) The registered manager must 28/02/06 ensure residents’ care plans state “how” individual care needs are supported. The registered manager must 31/01/06 ensure medication administration records are signed when medication is given and/or indicate reason for omission. The registered manager must ensure residents who receive “as required” (PRN) medications have care plans in place. The registered manager must ensure the dietary health care needs of residents are met. I.e. ensure weighing scales are working at all times. The registered manager must ensure all residents are provided with up to date and the correct complaints procedure. DS0000039103.V250057.R01.S.doc 3 OP9 13(2) 4 OP9 13(2) 28/02/06 5 OP7OP8OP 15 15,12 28/02/06 6 OP16 22(5) 28/02/06 Birch Lawn Resource Centre Version 5.0 Page 23 7 OP19 23(2)(b) 8 OP25 23(2) (c)(p) 9 OP25 23(2) (c)(p) The registered manager must 28/02/06 ensure the unsightly broken ceiling tiles in the hallway are repaired. 28/02/06 The registered manager must send an action plan to the Commission for Social Care Inspection detailing the nature of the problem with the heating, and timescales for repair. A serious concern letter was sent to the responsible individual on the 18th October 2005. The registered manager must 18/10/05 monitor and record four times a day temperatures of rooms throughout the building. A serious concern letter was sent to the responsible individual on the 18th October 2005. A copy of the record of temperatures was required to reach the Commission for Social Care Inspection office by 26th October 2005. (This was achieved) The registered manager must undertake regular recorded hot water temperatures from residents’ sinks. The registered manager must ensure the member of staff who has been employed without a CRB and POVA check does not have contact with vulnerable residents until the checks are received and seen to be satisfactory. The registered manager must ensure all appropriate employment checks are undertaken on staff prior to commencing in the home. The registered manager must ensure the requirements made DS0000039103.V250057.R01.S.doc 10 OP25 17, 23 31/01/06 11 OP29 19(1) 18/10/05 12 OP29 19(1) 31/01/06 13 OP38 23(4)(a) (b) 31/01/06 Page 24 Birch Lawn Resource Centre Version 5.0 (c) by the Hampshire Fire and Rescue service are carried out without delay. This requirement has been repeated. A further failure to comply will result in enforcement action. The registered manager must ensure staff receive regular fire drills and training The registered manager must ensure staff fire training records fully detail the names and numbers of staff who attended training. The registered manager must risk assess the resident who wishes to have his bedroom door propped open against the risk of fire. The registered manager must have access to all records held in the home. This requirement has been repeated. A further failure to comply will result in further action being taken. 31/01/06 14 OP38 15 OP38 18(1) (c) 23(4) (d)(e) 17,18, 23 31/01/06 16 OP7OP38 12(3) 23(4)(a) 31/01/06 17 OP37OP38 17(2) (12(1) 13(4) 28/02/06 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 The registered manager is advised to delegate a member of staff to regularly clean the medication cupboard and stock monitor. Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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 Birch Lawn Resource Centre DS0000039103.V250057.R01.S.doc Version 5.0 Page 26 - 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!