Inspection on 15/06/06 for Birkdale

This inspection was carried out on 15th June 2006.

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

Birkdale 21/10/08

Birkdale 15/12/06

Birkdale 16/02/06

Birkdale 24/05/05

Birkdale 03/12/04

Birkdale 01/07/04

Birkdale 12/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Birkdale Station Hill Oakengates Telford Shropshire TF2 9AA Lead Inspector Joy Hoelzel Key Unannounced Inspection 15th June 2006 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 Birkdale DS0000049825.V297433.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. Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birkdale Address Station Hill Oakengates Telford Shropshire TF2 9AA 01952 620 278 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) The Keepings Ltd Miss Rebecca Elizabeth Lambourne Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate 29 persons, whilst the person named on the attached schedule (not to be displayed) is resident. 16th February 2006 Date of last inspection Brief Description of the Service: Birkdale, one of two homes owned by The Keepings Ltd, is a Care Home providing accommodation and personal care for up to twenty-eight people over the age of sixty-five. Weekly fees range from £345.90 -£354.00. Situated close to Oakengates Town centre it is accessible to a variety of local amenities and public transport. A large, two-storey, detached property it provides single and twin-bedded accommodation with communal sitting/dining areas. There is generous car parking space to the front and a sheltered garden to the rear. Access to the rooms on the first floor is facilitated by a passenger lift. Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection is the first of key inspections for 2006/07 and took place over six hours on Thursday 15th June 2006. It was conducted by two Commission for Social Care Inspection regulation inspectors. Twenty eight of the thirty eight National Minimum Standards for older people were inspected. Twenty nine people are currently living at the home staffing levels appeared to be satisfactory. The ladies and gentlemen were observed to be in all areas of the home and garden engaging in various daily activities. What the service does well: What has improved since the last inspection? What they could do better: Several of the requirements made on this occasion are the same as some made May 2005 and February 2004, these include: Requirements made concerning contracts of terms and conditions for residents, locking storage in bedrooms, robust management of resident monies, excessive hot water temperatures and inadequately maintained bedrails. Furthermore, many of the shortfalls observed as a result of the CSCI Pharmacist inspection in 2004 appear to have not been remedied consistently resulting in a further breach of the regulations. Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 6 The pharmacy inspector will be contacted and asked to visit the home. The home must ensure that the care plans contain the concise and accurate details of the care interventions required to undertaken by the staff. 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. Birkdale DS0000049825.V297433.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 Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 1, 2,3 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. Service users records contain many of the necessary details to show the home has checked people can be looked after properly, and what the contractual terms of living at Birkdale entail. However, these need further expansion to clearly show all needs and interests of the people thinking about moving into the home have been taken into account. EVIDENCE: The statement of purpose and service user guide have recently been reviewed and updated and contain the current information regarding the home, staffing and the service on offer. Four sets of residents’ records were looked at in depth. These all showed that the home had undertaken their own assessment of the person involved as part of moving into the home. Birkdale use a well-designed form for this purpose. However, lack of attention to detail on the forms meant it was not clear if the assessments were carried out prior to admission. Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 9 The care plan records contain details of the home terms and conditions of residency as well as copies of any contracts issued by the placing authority. When this information was looked at, it was seen that the terms for two residents has meant that additional weekly top up fees have to be paid by someone other than the person moving into the home. There wasn’t any information on the home contract to outline who was to be responsible to pay these monies. This needs to be clearly identified in the appropriate section of the contract for the person moving into the home to assure people everything is ‘above board’, and all parties are aware of their responsibilities for this matter. Residents appeared to be happy with the lifestyle offered at Birkdale, and one lady commented in a recent review with her social worker: ‘I cannot fault it – if I had to go into a home this is the one I’d choose – I am very happy.’ Another resident introduced to inspectors also stated that before she moved into the home she came with her daughter for a look round – and although she had a good few homes to see, she knew she would be happy living there, and decided there and then to ‘look no further’. Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 7,8,9,10 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. Care plans and medication administration paperwork contains records of some necessary details required, however some omissions of important information has the potential of placing service users at risk of harm. EVIDENCE: Four case files were selected for inspection and included the care plans for persons most recently moved into the home. Records were seen to contain a variety of information to continue to assess and monitor the care people needed. The home carries out a 7-day assessment of people when they move in to make sure they get as much information as possible about the person. Observation of the case files evidence the home has made efforts to improve this paperwork; they have introduced forms to look at people’s meal time preferences following research of good practice information for this matter. Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 11 However, records were still seen to require more information to show the home and staff team know how to meet people’s individual needs in a safe and professional manner. This was highlighted upon the observation of an individual being assisted to move by two carers. The technique the staff used for this task was not a safe approved method. Examination of the manual handling assessments for four people, showed that there was a lack of information about what techniques and equipment are necessary to safely move them from one place to another, including the action needed in the event of a fall/emergency. This issue was discussed at the end of the inspection with the manager. Care plans for peoples specific needs also need more attention to detail. • The records of two people with leg problems did not give enough guidance to staff about managing these problems in their day-to-day care delivery. • People with a history of falls did not have any information to monitor this in order to ensure this risk was kept to a minimum. • The nutritional needs of a person did not identify that the individual needed supplementary nourishing drinks and puddings, although the hospital discharge letter passed this information on. In addition, the layout of the care plan forms meant that there was not much room to add more information at a later date. Although it is positive the home have created a form to show residents are invited to be involved in their care planning, this form was not dated and therefore could not demonstrate when or how often they are involved in this process. It was identified that the processes for the safe storage and administration of medication remained unsafe; a further support visit from the Pharmacist Inspector will be requested. In the mean time, the home manager was advised to prioritise improvements for: • Systems to store manage and administer refrigerated and Controlled Drugs. • The way the home monitors the receipt of all of its medications. • How changes in medication prescriptions for medication such as steroids and ‘blood thinning’ tablets are recorded on administration records. • Ensure medicines are given straight from the bottle to the person they are prescribed for without placing them in a pot not labelled by the chemist. • Risk assessment for and suitable storage to enable a person to safely administer his /her own medications. A complaint (also referred to in Standard 16) highlighted that the system for acquiring prescriptions at weekends had failed and resulted in a resident not Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 12 receiving their medication for some 24 hours. This was acknowledged by the home and steps have been taken to ensure that this should not happen again. Observation of staff providing the care showed staff were respectful and courteous with residents. However, lack of locks and ‘vacant /engaged’ signs on communal toilets and bathroom areas meant peoples privacy was challenged when they used these facilities. It is inappropriate to have a ‘bath list’ on display outside the office. Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 12,13,14,15 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. Staff have a good understanding of the residents support, dietary and leisure needs and use this to assist them to exercise choice and control in their lives. EVIDENCE: The home has a variety of systems in place to make sure people are involved in the day to day activities in the home. A free standing ‘pub – style’ blackboard tells people what the activity of the day is on one side, and the main meal of the day on the other side. Discussions with staff in groups as well as in private confirmed that the home encourages and welcomes a varied lifestyle for the people living there. Visitors to the home include clergy from neighbouring parishes as well as the Salvation Army. Regular social events with families of residents and staff were especially reported to be enjoyable. A summer fete is currently being planned. A programme of planned activities is compiled by the Deputy Manager, and was seen on display in the lounge and hall areas. Staff reported that people were looking forward to going to Weston Super Mare shortly. It is noteworthy Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 14 that the home is arranging this excursion two days in a row to ensure everyone who wants to go has the opportunity to do so. Residents are able to choose their meal on the same day to reduce the chance they may not remember what they ordered. All people spoken to said that their main course served at lunchtime tasted as appetising as it looked, although a few people did comment that the sponge pudding for dessert was dry. Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16,18 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures are in place for dealing with concerns, complaints and adult protection issues. EVIDENCE: One complaint has been forwarded to the Commission for Social Care Inspection for further consideration following the complainant being unsatisfied with the response from the home. This concern is still ongoing and has yet to reach a satisfactory conclusion. The recordkeeping relating to this complaint was looked at in depth, to confirm that the home management team had fully investigated the issues of concern. The complaint procedure is readily available in the statement of purpose and service user guide; a copy is also displayed on the notice board at the entrance to the home. The homes procedure for adult protection and the prevention of abuse has recently been reviewed (February 2006), staff are encouraged to read the procedure and are required to sign to say they have read and understood it. A video on adult protection is also available for staff use. The registered manager demonstrated a good knowledge in the local adult protection procedures. Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Op 19,21,22,24,25,26 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. Although ongoing refurbishment of the home continues to improve the living environment within the home. The current arrangements do not always ensure residents have a clean, safe, and homely place to live. EVIDENCE: Both inspectors conducted separate tours of the home, accompanied by staff members. Most parts of the home were spotlessly clean and are a credit to the house keeping team. Staff reported that the home has been subject to a lot of refurbishment and decoration including the replacement of many carpets and furniture. Some doors to the private accommodation have been fitted with an appropriate door closure that activates to close the door in the event of an emergency. During the tour of the building some doors were being wedged open by wooden blocks or pieces of furniture. If it is a person’s preference to have a fire door open then the appropriate door closures must be installed. Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 17 This is an ongoing issue from the last two statutory inspections, the lack of compliance with this requirement compromises the safety of the people living and working at the home. The agreement of the offer of a lockable facility on resident’s private rooms has been included in the care plan. The door locking facility must be available on all private bedrooms so as to offer a true choice to each resident of having their door locked or not. Service users were seen to appreciate the sunshine and hanging baskets in the private patio area outside the conservatory, where plenty of garden furniture is available for outdoor use. As well as looking round the communal areas, a selection of bedrooms and bathrooms were seen, including those occupied and used by the people whose records were examined. One of these rooms had a heavily stained carpet and an unpleasant odour. Other maintenance issues seen to require attention included: • Testing of the alarm bell in one of the lifts showed it was not working. • Random testing of hot water in bathrooms was satisfactory with the exception of one on the first floor – which was running at 50 Degrees Centigrade. This was discussed at the end of the inspection with the advice it be locked and taken out of use and appropriate warning signage be used. • Two radiators seen in a corridor and a resident’s bedroom were in need of protective guards. • The mirror on a wardrobe door was cracked with a sharp edge exposed. • Many bedrails seen had not been fitted correctly. • Bath seats were seen to be showing signs of wear and tear – posing infection control as well as cleaning hazards. The bath used for a person with an infection was seen to have a damaged surface where the enamel had become chipped and worn. • A call cord seen in one bathroom was too high to use by people sat in the bath area. • The thermometer in the room used to store medication was broken. Clinical waste disposal systems need to be reviewed. In the bedroom of a person with an infection, there were no bins available to keep the infected linen bag or clinical waste bag from contact with the carpet. • The bathroom this person used did not have a clinical waste bin to dispose of dressings etc. • Many clinical waste bins seen in use could not be opened without touching the bin lids. The above issues all challenge effective infection control management in the home. Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 18 Not all areas (private and communal) where personal care is undertaken are provided with adequate hand washing facilities for staff use and for infection control purposes During the home tour it was seen that there was an alcove in the corridor housing the open plan kitchen area. This area is designated for smokers. It was reported that 3 people use this facility to smoke. This issue was discussed at the end of the inspection, and it was agreed for the registered person to seek the advice of the Environmental Health Officer about this matter. Birkdale DS0000049825.V297433.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): OP 27,28,29,30 Quality in this area is adequate but poor in the homes recruitment practices. This judgement has been made using available evidence including a visit to this service. There are clear lines of accountability within the home’s management structure; improved communication systems have been developed. Although documentation relating to staff has improved, the home is putting service users at great risk (and breaching regulations), by employing staff that have criminal convictions. EVIDENCE: At the time of the inspection staffing levels appeared to be appropriate for the number of people living at the home. The manager was on the premises supported by one senior care, four care staff with additional catering and domestic personnel. A staffing rota is maintained for each shift. The care staff were observed to be generally very busy attending to the needs of service users. A comment was made by a visiting healthcare professional that the staff are ‘very helpful’. One service user commented that at times especially during the night staff can sometimes be’ giggly and noisy’. But for most part the staff are ‘helpful’. The recently revised statement of purpose details the National Vocational Qualification in care obtained by staff. One staff member discussed the training and how she was enjoying it. A recently recruited staff member spoke of the intention of gaining a place for NVQ training at the next student intake. Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 20 Three staff personnel files were selected for inspection and included the file of the most recent recruitment. All files contained a completed application form, copies of references and induction programme. The criminal record bureau disclosure for one staff member shows a recent conviction for an offence. The manager stated that a decision has been made by the owners to continue with this person’s employment. The file did not contain details of the decision making process or any additional supervision or support that may be required. The last recorded supervision session was dated 30/01/06. The manager stated that all staff have applied for a criminal record bureau disclosure, some disclosures had been destroyed following the last inspection. It was recommended to the manager that details are kept of the date when the disclosure was received, prior to destroying. A training matrix has been developed to record all training needs of staff and the dates when the training is taking place. The statement of purpose states staff have received training in moving and handling, fire safety, food hygiene, first aid, medication management, the control of infection and signs of abuse. Training is currently being arranged for continence management and bereavement. Birkdale DS0000049825.V297433.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): OP 31,33, 35,38 Quality in this area is adequate but poor in health and safety aspects. This judgement has been made using available evidence including a visit to this service. The manager is approachable and supportive, and is currently developing systems to improve the day-to-day management and service provision. EVIDENCE: The manager has recently undergone the formal application for the position of registered manager, she is currently working towards the registered managers award and plans to complete the course in July 2006. Service users, staff and visitors all made positive comments about her style of management. All changes reported have been a ‘change for the better’. A visiting GP stated that she is satisfied with the level and amount of contact regarding the health care needs of the people living at the home and feels that problems are acted upon expediently when concerns are identified. Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 22 The manager stated that at present the home does not operate a quality assurance system but plans have been made to introduce a scheme later on in the year. Satisfaction surveys have been distributed to staff and service users but are not dated and have not been audited to measure the success of the service. The home has a good system to show they make sure staff are aware of policies and procedures. A form attached to all policies, including the one for managing residents finances and valuables is signed by staff members to confirm they have read and understood the contents of the policy. The home has a comprehensive policy that offers guidance to staff how to manage residents’ finances and valuables. Information seen in two out of three sets of admission records for residents showed whether the home was looking after monies or valuables on the residents’ behalf. When the contents of the cash box used to store residents monies was checked against the forms used to record their expenditure, all balances tallied. However, some loose coins seen in the cash box could not be accounted for. The above two issues show this system needs minor adjustment to make sure it is robust. In order for the home to improve the way it manages the safe installation and maintenance of bedrails, a copy of the necessary risk assessment guidance from the Health and Safety Executive was provided the day after the inspection. CSCI have raised concerns about this issue for some time. This must be prioritised. Birkdale DS0000049825.V297433.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 4 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 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 2 2 2 2 X 2 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 Birkdale DS0000049825.V297433.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 OP2 Regulation 5 (1) (b) Requirement Timescale for action 30/09/06 2 OP3 14 (1) Sch 3(1)(a) 3 OP7 15(2) 4 OP7 15, Sch 3 (1)(b) All service users contracts of terms and conditions with the home in respect of accommodation to be provided must include the amounts and methods of payments by those responsible for doing so. Needs assessment forms must 30/09/06 show details of when the assessment was carried out, and include all aspects of a persons need to ensure a safe well planned admission to the home. The care plan of each individual 30/09/06 must be updated to show all details of the care a person needs and prefers and reflect the person is involved in this process regularly. Moving and handling 01/08/06 assessments must contain all information to guide staff how to move the person safely from one place to another, identifying moving techniques and equipment necessary for any such manoeuvres, including picking a person up following a fall. DS0000049825.V297433.R01.S.doc Version 5.2 Birkdale Page 25 5 OP7 15, Sch3 (1)(b) 12 (1)(2), 13 (1) Sch 3.3 (k, m) 12 (1)(2), 13 (1) Sch 3(3) (k, m) 13 (2) Sch 3(3) (i)(k) Falls risk monitoring must be implemented as part of care planning and management. Care plan records must include all necessary information provided from associated professionals including hospital staff to ensure all dietary needs are met. The registered person must ensure that all care interventions recorded in the care plan are carried out efficiently and effectively by allocated staff. Systems for the storage and administration of all drugs including Controlled Drugs must meet the Royal Pharmaceutical Society of Great Britain guidelines. The Controlled Drug cupboard must not be used for storage of any other items such as money. The home must implement a system to effectively monitor the accurate receipt of all medications it receives in the home. All changes to medication prescriptions must be recorded clearly on the medicine administration records. The home medication administration system needs further improvement so that the practice of ‘double dispensing’ medications doe not continue. Locks and ‘dignity signage’ must be provided for communal toilets and bathrooms. Where service users wish their bedroom door to be kept open this must be effected by an approved system (e.g. by linking the particular door into a ‘magnetic catch/fire alarm’ DS0000049825.V297433.R01.S.doc 30/09/06 6 OP8 30/09/06 7 OP8 30/09/06 8 OP9 01/08/06 9 OP9 13 (2) Sch 3.3 (i)(k) 13 (2) Sch 3.3 (i)(k) 13 (2) Sch 3.3 (i)(k) 13 (2) Sch 3.3 (i)(k) 12 (4)(a) 23(4)(c)(i) 01/08/06 10 OP9 01/08/06 11 OP9 01/08/06 12 OP9 01/08/06 13 14 OP10 OP19 30/09/06 30/09/06 Birkdale Version 5.2 Page 26 15 OP20 16 (1) 23 (2) (eh) 16 OP21 16 (1) 23 (2)(j) 16 (1) 23 (2)(j) 17 OP21 18 OP22 19 OP22 20 OP24 21 OP24 16 (1) 23 (1)(a), 23 (2)(a)(n) 16 (1) 23 (1)(a), 23 (2)(a)(n) 16 (1) 16 (2) (c), 23 (2)(e, f) 16 (1) 16 (2) (c), 23 (2)(e, f) 12(4) system). Previous timescale May 2005, 31/03/06 not met. The registered person must seek and follow the advice of the Environmental Health officer concerning the smoking area being in near proximity to the open plan kitchen. Baths seats and surfaces must be repaired so that they are readily cleanable to promote infection control. All hot water in areas accessible to service users must be regulated so that the maximum temperature is around 43 Degrees Centigrade. The alarm bell in the lift must be regularly checked and in good working order. Call bells must be accessible in all communal areas including bathrooms. All bedroom furniture must be in a safe condition – damaged mirrors must be repaired. Locking storage must be available for all service users; priority must be given to those who need safe storage for medicines they administer themselves. Doors to service users private accommodation must be fitted with locks suited to service users capabilities. All service users bedrooms must be free from unpleasant odours. 30/09/06 30/09/06 01/08/06 01/08/06 01/08/06 01/08/06 30/09/06 22 OP24 30/09/06 23 OP24 16 (1) 16 (2) (c), 23 (2)(e, f) 30/09/06 Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 27 24 OP24 25 OP25 16 (1) 16 (2) (c), 23 (2)(e, f) 23 (2)(p) Carpets in service users bedrooms must be kept clean and free from large unsightly stains. The home must have evidence to show the temperature in the storage room for medication is maintained around 25 Degrees Centigrade. Systems to dispose of clinical waste and infected linen must be improved to ensure foot operated bins are used for this purpose. These must be located in areas of the home accessed by people known to have infections. Hand washing facilities must be available for staff at the point of each delivery of care. All staff must have a satisfactory criminal record bureau disclosure. Robust procedures must be adopted for assessing the integrity and good character of employees. Recordkeeping for managing service users monies must be further developed so they can demonstrate they account for all monies and valuables held on service users behalf. Recordkeeping for bedrails must be improved to show that a full risk assessment in line with Health and Safety Executive guidance has been implemented to ensure all bedrails are installed and maintained correctly. 30/09/06 30/09/06 26 OP26 13 (3), 16(2)(e)(j )(k), 23 (2) (d), 23 (5) 13(3) 19 30/09/06 27 28 OP26 OP29 30/09/06 01/08/06 29 OP35 13 (5), 20 Sch 4.8,4.9 30/09/06 30 OP38 13 (3-6) 23(2)(b), (c) Sch 3.3 (j) 01/08/06 Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 28 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 OP26 Good Practice Recommendations It is ‘Recommended’ that consideration be given to the installation of automatic sluicing disinfectors, on each floor, for the safe disposal of bodily waste. It was recommended that details and an audit trail of criminal record bureau disclosures for staff be kept. 2. OP29 Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE 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 Birkdale DS0000049825.V297433.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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