Inspection on 05/06/06 for Bluebrooke Residential Care Home

This inspection was carried out on 5th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bluebrooke Residential Care Home 20/04/09

Bluebrooke Residential Care Home 04/12/08

Bluebrooke Residential Care Home 23/04/08

Bluebrooke Residential Care Home 23/05/07

Bluebrooke Residential Care Home 29/10/05

Bluebrooke Residential Care Home 28/07/05

Bluebrooke Residential Care Home 02/03/05

Bluebrooke Residential Care Home 14/09/04

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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 Catshill Residential Care Home Catshill Residential Care Home 242 Stourbridge Road Catshill Bromsgrove Worcs B61 9LE Lead Inspector R McGorman Unannounced Inspection 12:30 5 ,6 &12th June th th 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 Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 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. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Catshill Residential Care Home Address Catshill Residential Care Home 242 Stourbridge Road Catshill Bromsgrove Worcs B61 9LE 01527 877152 01527 557409 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) Oldfield Residential Care Limited Mr Anastasis Kayiatou Care Home 46 Category(ies) of Dementia - over 65 years of age (46), Old age, registration, with number not falling within any other category (46), of places Physical disability over 65 years of age (46) Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The four bedrooms on the top floor of the home are not used for service users with mobility needs. Staffing levels are increased to match the Residential Forum`s recommended levels which are that seven staff are on duty throughout the waking day. 29th October 2005 Date of last inspection Brief Description of the Service: Catshill Residential Care Home is registered to provide personal care for up to fortysix older people who are frail, who may have a physical disability, or who may have mental health problems. The home has a high proportion of service users who have a dementia illness. The large, detached property, standing in its own grounds, is situated in a pleasant residential area, approximately two miles from Bromsgrove town centre. There is an enclosed garden which is accessible to service users. The home had been under the same ownership for many years, until purchased by Oldfield Residential Care Limited in April 2004. The need for development in several areas was identified, and progress has been evident, during the past eighteen months, in service delivery, and in the upgrading of the premises. The stated aim of the home is to ensure that all care provided within the home is personal and unique, that each individual is treated with the utmost respect that ensures their privacy, and that high professional standards are maintained in every way. The range of fees varies between £360 & £390 per week. The home has been without a registered manager for the past six months. Responsibility for the day-to-day running of the home was initially undertaken by the deputy manager, with assistance from the manager of Oldfield Residential Home, together with the other managers within the group. Subsequently an appointment was made to the vacant position, and the application for registration was processed. Mrs Carole Hutchinson was registered as the care manager on 9th June 2006. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection involved an unannounced visit to the home, the purpose of which was to monitor the care provision in relation to the stated aims and objectives of the home, and to follow up previous requirements and recommendations. Enquiries were also made in relation to concerns brought to the Commission in respect of staffing matters at the home, which were followed up as part of the routine inspection process. Service users and staff were consulted about their experiences of living and working at the home, and every one was very positive in their comments. Visitors and professionals who were spoken with, on the day of the inspection also expressed their satisfaction with the care provided. A tour of the premises was undertaken, and the records kept in respect of the maintenance of equipment and safe working practices, including the fire log, were also checked. The care records of several residents were seen, and the files of some staff were also inspected. The Acting Manager and other staff at the home were open and co-operative, and made themselves readily available to assist with the inspection. Time was also spent with the deputy manager discussing areas of work for which she had specific responsibility, including the administration of medication. A Director of the Company was also present during part of the inspection What the service does well: A warm welcome to the home is given to visitors, and the atmosphere is relaxed and friendly. The premises are well maintained, and the house is comfortable, clean and warm, with good quality furnishings. Following the resignation of the Registered Manager several months ago, good support has been provided to the acting manager by senior staff from the other homes in the group. There is a commitment from staff to providing good care, and comments from service users confirmed that this is achieved, and that they are very satisfied with the care received. Arrangements for the administration of medication are satisfactory. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Develop more detailed documentation, in care planning and risk assessment. Provide each service user with a contract or terms and conditions of occupancy. Make arrangements to ensure that service users are offered more social, cultural, recreational and occupational opportunities, and encourage more community involvement. Comments from some service users confirmed that they would prefer to have more organised activities. Provide a structured, specialist training programme for staff, which will enable them to more effectively care for service users. Demonstrate an organised approach to the management of staff, with ongoing monitoring and supervision to ensure consistent delivery of care. Introduce a quality monitoring system. Develop the person centred approach to the care of service users. Implement more robust recruitment procedures Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 7 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. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 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 Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 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): 1,2,3,5 & 6 Quality in this outcome area is adequate This judgement has been made using available evidence, including a visit to this service. Prospective service users are provided with information to assist them in making a decision about living at the home, although confirmation should be provided for all residents in a contract or terms and conditions of occupancy. The admission procedure provides an appropriate introduction to the home. The pre-admission assessment should be more specific to the provision of dementia care, to ensure that the home is able to meet the identified needs of service users. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 10 EVIDENCE: The Statement of Purpose and Service Users Guide for the home have been reviewed, and now provide residents with the relevant information to enable an informed choice to be made about their future care needs. A written contract/statement of terms and conditions of residence, which includes all the information detailed in Standard 2.2.of the National Minimum Standards, has not been issued to all service users living at the home, although new service users are given the appropriate documentation on admission. A pre admission assessment for all prospective service users is undertaken, either at home or in hospital, following an initial referral. The need for the assessment documentation to be adapted to include the provision of dementia care, was discussed with the Acting Manager. A satisfactory admission procedure is in place, although this needs to include more detail about dealing with emergency admissions to the home. A visit to the home is encouraged, and prospective service users are invited to spend time with the resident group and to have a meal. Arrangements may also be made for a short stay, if this is preferable, prior to making a decision about taking up residence. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 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 & 10 Quality in this outcome area is adequate This judgement has been made using available evidence, including a visit to this service. The plan of care contains relevant information, although rather limited, therefore, more detailed records need to be maintained, to ensure that the personal and healthcare needs of residents are fully met. Risk assessment procedures enable the needs of service users to be identified, and ensures their safety and protection as far as possible. The policy and procedures covering the administration of medication ensure the protection of service users. Staff demonstrated a good understanding of the needs of service users, and offer care in a way that encourages and promotes their independence. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 12 EVIDENCE: A plan of care is produced for each service user based on the initial assessment undertaken prior to admission. The care plans of several service users were seen during the course of the inspection, and there had been some progress made in their development. The information provided is relevant, although more detail is needed. Specifically, all interventions with service users need to be recorded, and the plans define how the care is to be implemented, the outcomes that are intended and the future proposals for the individual. Information is also recorded in the daily log, although these comments were found to be repetitive, and not very informative. The care plans should be reviewed at least monthly, and signed by the service user or their representative, to confirm their involvement and agreement. The need for a formal review to be arranged at least annually, was also discussed with the acting manager, and should include all those involved with the service user. The involvement of service users in determining their care provision, and the development of the person centred approach at the home, were acknowledged by the acting manager as fundamental in achieving the aims and objectives of the home, which are to provide high professional standards of care. The health and personal care needs of residents are monitored and the home is well supported by the Primary Health Care Team. Specialist treatment can be accessed, and the advice of the continence nurse is sought when necessary. Completed risk assessments were seen for the moving and handling of service users, nutritional needs, tissue viability, and the use of specialist aids and adaptations. A body map is also completed for service users when appropriate. Staff were observed administering medication to service users, and the correct procedures were being followed. The Medication Administration records were checked, and had been completed to a satisfactory standard. The deputy manager who holds responsibility for the administration of medication at the home, provided assistance to the Inspector during this part of the visit. Evidence to indicate that service users are treated with dignity and respect was observed in the interactions of staff with service users, and was also confirmed in discussion with them. Visitors were equally complimentary about the care provided to their relatives and friends at the home, and about the kindness of staff. Professionals spoken with personally were also positive about the care provided to service users. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 13 Comments from all concerned included the following: • I’m very happy here • I have a lovely room and a comfortable bed • The food is good • Mostly everything is fine • I would obviously rather be at home, but it’s reasonable here • The food is usually quite good and varied • I would like to be able to do some gardening • There could be more activities available • People are looked after here better than in hospital • I feel I’m included in my mothers care • My mother considers Catshill to be her home • Everyone is made very welcome • I think it’s wonderful Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 14 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 & 15 Quality in this outcome area is adequate This judgement has been made using available evidence, including a visit to this service. The absence of a co-ordinated programme of social and cultural activities, which is suited to the individual needs of service users, limits the opportunities available to them, and consequently affects their quality of life. Service users have freedom in regard to their contacts, both within and outside the home, which enables a good quality of life to be maintained, although more involvement with the local community would be beneficial. The practices at the home enable service users to exercise choice and control over their lives. Service users are offered a choice of nutritious, wholesome and well-balanced meals. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 15 EVIDENCE: There has been further development in regard to the recreational needs of service users, with specific time spent by care staff to providing activities during the afternoons. Discussions with staff identified an enthusiastic approach to this area of their work, although the appointment of an activities co-ordinator would further enhance facilities for service users. The leisure needs of service users with dementia, and other cognitive or sensual impairment, requires a specific understanding by staff, to enable a more appropriate and effective response to be provided, therefore training would be beneficial. The involvement of family and friends is actively encouraged, and visitors are always made welcome at the home. Consideration now needs to be given to increasing the involvement of the home with the wider community. Service users are encouraged to exercise choice, as far as they are able, about when to get up or go to bed, and how they wish to spend their day. The activities of daily living are flexible and service users are encouraged to express their views and to make choices. Comments from service users and staff, in regard to the meals, were all very positive. The menu confirmed that a choice is offered, and alternatives are always available. Special diets are catered for, and individual preferences recorded. A record of the food provided to individual service users is now being maintained at the home. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 16 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 & 18 Quality in this outcome area is adequate This judgement has been made using available evidence, including a visit to this service. The complaints procedure is implemented at the home, in an open and efficient manner, to ensure the protection of service users. Further development of the policy and procedures relating to the Protection of Vulnerable Adults, to include staff who may be unsuitable to work with vulnerable people, should prevent service users being placed at risk of harm or abuse. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 17 EVIDENCE: A satisfactory complaints procedure has been produced and is accessible to residents and their families. Further development has been undertaken to include a record of comments and compliments also received by staff at the home. A complaint made in October 2005, and investigated under the Adult at Risk Procedures, found that the allegations had not been upheld. The management had responded in a very professional manner in assisting with the inquiry. The views of service users and their families were sought prior to the inspection, and the following comments were recorded: • The difference in my mother is amazing • I cannot praise the staff enough • The staff cope admirably well • Even the families are helped • The friendly greeting I get is wonderful • I am very pleased with the care my husband gets • The overall care is good • When it has been necessary to make comment, staff respond The policy and procedure on the Protection of Vulnerable Adults (POVA) has been reviewed recently, but the documentation does not include the procedure to be followed in relation to staff who may be unsuitable to work with vulnerable people. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 18 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): 19,21,23,24 & 26 Quality in this outcome area is good This judgement has been made using available evidence, including a visit to this service. The standard of cleanliness is satisfactory, the décor and furnishings are in good condition, and the building is well maintained, providing a comfortable and homely environment that ensures as far as possible the safety of service users. The ongoing development in relation to the facilities provided at the home, is effectively improving the quality of life of service users, although not all the work has yet been completed. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 19 EVIDENCE: Catshill Residential Care Home is a large, detached property, situated in an elevated position, approximately 2 miles from Bromsgrove. The building, which is generally well maintained, has been upgraded and extended, over several years to provide accommodation for up to 46 service users. There are 24 bedrooms in the original house, situated on three floors, 8 of which are shared rooms. The new wing has 13 bedrooms, 1 of these being shared accommodation, and all having en suite facilities. The home complies with the National Minimum Standards in many respects. The following upgrading and improvement work has been undertaken during the past 6 months: • Consideration has been given to the ratio of single to double bedrooms • Advice has been sought from the fire safety officer with regard to fire exits that are accessed through shared bedrooms • Privacy curtains are being fitted in all shared rooms • Several bedrooms have been redecorated and new curtains and carpets fitted • New furniture has been provided in some bedrooms • Improvements have been made to some bathrooms, shower room and toilets • Storage for wheelchairs has been provided • Upgrading to the kitchen includes redecoration, new shelving and new kitchen units • Equipment has been replaced in the kitchen – dishwasher, deep fat fryer and freezer • Exposed pipe-work has been guarded Further improvements are planned with the ongoing upgrading of bathrooms throughout the home, and further fire protection being implemented. Door locks are being fitted to bedroom doors, and lockable furniture provided for service users. Service users in double rooms have made a positive choice to share with each other, and a record is now kept of this arrangement in their individual care plans. The Proprietor confirmed there are no outstanding requirements following a visit to the home by the Environmental Health Officer in January 2006. The Fire Safety Precautions within the home are satisfactory. The Fire Log book was checked, and appropriate records are being maintained. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 20 Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 21 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 & 30 Quality in this outcome area is adequate This judgement has been made using available evidence, including a visit to this service. The staff team is fairly stable, and staffing levels are being maintained at an adequate level to meet the needs of service users. The training programme for staff needs to ensure that each member of staff is competent, has a clear understanding of their role, and therefore is able to deliver care appropriately. Procedures for the recruitment and selection of staff need to be sufficiently robust in their application to fully ensure the protection of service users. EVIDENCE: The staff rotas indicated that staffing is maintained at the levels agreed as a condition of registration, and it was confirmed by the manager, that these are adequate for the needs of service users. There have been some staff changes recently, although many staff have worked at the home for several years. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 22 Several staff were interviewed, and confirmed that they enjoyed their work. Their comments were very positive about their employment at the home, and the training opportunities that were now provided. The staff group appear to be enthusiastic and well motivated, although some are quite young with limited experience. Two members of staff are doing the National Vocational Qualification Level 2 in Care, and several more staff have applied, and will commence NVQ training in the near future. One person is doing Level 3, and the deputy manager is taking Level 4, together with the Registered Managers Award. In addition the acting manager has applied to commence the Registered Managers Award, commencing in September2006. Five domestic staff are also doing the NVQ Level 2 in Hotel Services. A training programme is being developed, and recent courses have included the following: • Basic food hygiene • Fire awareness • Medication administration • Sensory impairment • Continence management Further training is being planned to include the mandatory courses, and also specific care related areas e.g. dementia awareness and person centred care, the protection of vulnerable adults and abuse awareness. The acting manager was reminded that previously identified training remains outstanding in respect of communication, specifically for senior staff, and the Full First Aid at Work Course. The need for a review of the training needs of each member of staff, and the development of an individual training and development assessment and profile was again identified. A satisfactory recruitment and selection policy and procedure is in place at the home, although it is not always followed. The files of several members of staff were selected randomly, but they did not all contain the relevant documentation as listed in Schedule 2 of the Care Homes Regulations. Some references provided limited information about the applicant, whilst others did not have two written references. Evidence of identity had not always been confirmed. Criminal Records Bureau checks had been undertaken, for all staff working at the home currently. The recruitment procedures at the home should be implemented thoroughly, to ensure that appropriate staff are appointed, who are experienced in caring for people with dementia, who understand cultural issues, and have good communication skills. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 23 Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 24 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): 31,33,35,36,37 & 38 Quality in this outcome area is adequate This judgement has been made using available evidence, including a visit to this service. The absence of a registered manager in recent months has delayed further progress being made, including the implementation of formal staff supervision. Development of the quality assurance system will enable the views and opinions of service users to have a greater influence in how the home is run. The policies, procedures, and records maintained at the home, comply with legislative requirements, and therefore help to safeguard the rights of service users. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 25 EVIDENCE: The home had been without a registered manager since September 2005, until 9th June 2006, when registration was granted to Mrs Carole Hutchinson. Consequently, the ability of the management to implement the changes that had previously been identified in several areas of service provision, has been limited. The responsibility for the day-to-day running of the home was initially undertaken by the deputy manager, and latterly by the acting manager, who have both coped well with assistance from other managers from within the Oldfield Group. A quality assurance system is yet to be implemented at the home. The Mulberry System is to be introduced, but the management situation has delayed its development. The management of the home confirmed that staff do not have any involvement with the financial affairs of service users. Arrangements are in place for the family or a representative to take responsibility, where a service user lacks capacity or does not wish to be involved. A small petty cash float is held for incidental purchases, and appropriate records are maintained. The records were not checked in detail during the inspection, although those seen had been completed to a satisfactory standard. Contracts are in place for the regular servicing and maintenance of equipment. The Fire Log indicated that weekly checks of the fire alarm system, and practice evacuations are undertaken. The Accident records had been completed appropriately, and Regulation 37 Notifications are made to the Commission, when appropriate. The Commission is now receiving regular reports on the conduct of the care home, from the Responsible Individual, in respect of the monthly visits to the home under Regulation 26. Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 26 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 2 2 X 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 2 X 3 2 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 3 2 Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 27 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 Timescale for action A contract or statement of Terms 30/09/06 and Conditions of Residence must be provided for each service user A detailed plan of care must be 30/09/06 drawn up with the service user or their representative, and provide clear guidance to staff on the actions to be taken to meet the changing personal and health care needs of service users. (Previous timescale of 31/12/05 not met) Care plans must be reviewed at 30/09/06 least once a month by staff. (Previous timescale of 31/12/05 not met) Suitable locks, which open with a 31/12/06 single action, must be fitted to all bedroom doors throughout the home Recruitment procedures must be 30/09/06 implemented in accordance with the requirements of Regulation 19, Schedule 2 & Standard 29 DS0000057561.V287581.R01.S.doc Version 5.1 Page 28 Requirement 2 OP7 15 3 OP7 15 4 OP24 23 5 OP29 19 Catshill Residential Care Home 6 OP30 18 7 OP30 13 8 OP33 24 9 OP36 18 A staff training and development programme must be introduced which meets the National Training Organisations specification (Previous timescale of 31/12/05 not met) Training must be provided for staff on all aspects of abuse and the protection of vulnerable adults A quality assurance system must be introduced in accordance with the requirements of regulation 24 and Standard 33.(Previous timescale of 31/12/05 not met) Care staff must receive formal supervision at least 6 times a year 30/09/06 30/09/06 30/09/06 30/09/06 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 2 3 Refer to Standard OP3 OP5 OP12 Good Practice Recommendations Specific documentation should be developed for the assessment of prospective service users with dementia The procedure for accepting an emergency admission to the home should be included in the statement of purpose Consideration should be given to appointing an Activities Co-ordinator to take responsibility for organising a programme of recreational activities for service users Opportunities for more involvement with the local community should be made available to service users 4 OP13 Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 29 5 OP18 A procedure should be developed in relation to staff who may be unsuitable to work with vulnerable adults, and who may need to be considered for inclusion on the POVA register The ongoing development of the premises should continue, and a programme of routine maintenance and renewal of the fabric and decoration of the premises produced Arrangements should be made for senior staff to undertake the Full First Aid at Work Course 6 OP19 7 OP38 Catshill Residential Care Home DS0000057561.V287581.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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