Inspection on 03/10/06 for Bole Hill View

This inspection was carried out on 3rd October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bole Hill View 20/10/08

Bole Hill View 05/11/07

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

CARE HOMES FOR OLDER PEOPLE Bole Hill View 2 Eastfield Road Crookes Sheffield S10 1QL Lead Inspector Shirley Samuels Key Unannounced Inspection 09:30 3rd October 2006 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 Bole Hill View DS0000067344.V312244.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. Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bole Hill View Address 2 Eastfield Road Crookes Sheffield S10 1QL 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) 0114 2683960 0114 2683960 None Sheffield Care Trust Mrs Gloria Iris Proost Care Home 20 Category(ies) of Dementia - over 65 years of age (20) registration, with number of places Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Three of the DE(E) beds may instead be used as DE. Where additional services are provided eg day care, outreach, escort duty, staffing for this must be over and above that required for the registered service. 09/3/06 Date of last inspection Brief Description of the Service: Bole hill view is situated in the crooks area of Sheffield. The local amenities are accessible and there is a regular bus service. The building is single storey and all the bedrooms are single. Bathrooms and toilets are close to bedrooms and there are a number of comfortable sitting areas and a comfortable dining area. The home provides respite care to people living with dementia. At the time of this inspection there was one permanent service user remaining who has lived at the home for several years. The manager stated via the pre inspection questionnaire that the current fee is £382.00, this is the fee charged to all service users. There are additional charges for hairdressing, chiropody, newspapers, toiletries and outings. The home has a statement of purpose and a service user guide which is displayed in the home and available to service users and their relatives. Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector from 9:30am –5.00pm. There were 8 service users in residence at the time of the inspection of which only one was permanent. All service users were seen, introduced to the inspector and spoken to briefly. Relatives were seen but were not spoken in any detail as they were collecting service users who were being discharged from the home. Observations were made of the interaction between service users and staff, a sample of records was examined and an inspection of the building was made. Three staff were interviewed in detail in addition other staff were spoken to briefly. The manager completed a pre inspection questionnaire, which gave details about the service provision, service users, staff and professional visitors to the home along with details of how the health safety and welfare of service users was maintained. Feedback was given to the manager, responsible individual and team leader. The inspector would like to thank the service users, staff and management for their co-operation throughout the inspection process. What the service does well: Although some issues were noted service users did not come into the home without first having their needs assessed by a social worker. There were procedures in place to try and make sure that service users health care needs were met. The home provides a respite care to service users from all around the city. The manager said that for some service users this means that they are unable to see their own general practitioner while in respite. In some instances this can be a problem, as local general practitioners do not have a sufficient medical history. In the main the medication procedures were safe. Service users were treated with respect and observations were made of their privacy being upheld. There were regular and varied activities within the home. Some staff said there should be more opportunity for service users to go outside of the home. The home has its own transport but staff said there was not always enough staff to drive and to provide escort. The respite service provides a welcomed break for cares. Some choose not to visit during respite stays but service users are able to maintain contact with family and friends as they wish. Service users are encouraged to make choices and to have as much control over their daily lives. They were able to choose clothing, what they wanted to eat, how to spend their day. There were systems in place to help orientate service users. For example, menu board with the correct date and choices of meals for the day, all the clocks around the home were noted to have the correct time, bathroom toilets and bedroom doors were labelled. Service users said they were given a choice at mealtimes and that they enjoyed the food. Staff were observed encouraging service users to eat and offering alternatives. There was a clear complaints procedure in place. The Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 Page 6 home has not received any complaints since the last inspection. The home was clean and reasonably maintained, although there were some problems with carpets that were stained despite regular shampooing. The majority of the staff team are trained to NVQ level 2 in care and training is ongoing. The line manager of the home makes regular visits, to monitor the service. Monthly visits are also made by a designated person who talks to staff makes observations and prepares a report on their findings and the action to be taken where issues are noted. 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. Bole Hill View DS0000067344.V312244.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 Bole Hill View DS0000067344.V312244.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): 2 & 3 Standard 6 does not apply to this service. Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. Each service user had a contact that detailed the terms and conditions of their stay at the home. Service users did not move into the home without first having their needs assessed. EVIDENCE: Three service user files were checked Contacts were seen on all three files. There was one of the contacts that were not signed by the service user or their representative. Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 Page 9 Assessments were carried out by a social worker prior to admission to the home. Staff said that increasingly the assessments did not always have enough information and did not reflect the needs of the service user. Staff said they had seen an increase in service users being admitted to the home, who have demonstrated aggression and challenging behaviour, which had not been mentioned in the assessment. The records of accidents included a number of reports involving service users “assaulting” other service users. The staff and managers expressed concerns about the closure of services that specialised in the care of people with behavioural problems, as they felt the outcome of this was inappropriate referrals being made to them. They also expressed concern about the lack of access to support when in crisis situations, for example when it becomes evident that a service user is inappropriately placed and placing themselves and other service users at risk of harm or abuse. Bole Hill View DS0000067344.V312244.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): 7, 8, 9 & 10. Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. Each service user had a plan of care they did not however include all the information required by the standards. Service users health care needs were met and in the main the medication standards and procedures were satisfactory. Service users were treated with respect and their right to privacy was upheld. Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 Page 11 EVIDENCE: Each service user had a care plan that detailed service users needs and records were kept of the care provided. They did not however contain details of the action required by staff to meet need. There was no indication of who contributed to the care plan and falls assessments were not signed and dated. Details of accidents were recoded on accident forms but not always recoded in the service users file. There was no details or guidance in care plans about how staff should approach service users who displayed challenging behaviour and aggression. All service users were not weighed on admission to the home and on a regular basis thereafter. Care plans were not reviewed monthly. Some of the procedures in the home required a lot of information to be duplicated, for example there was a bath sheet and a sheet for recording activities, separate to the service user file. All information relating to a service was not recorded in their file. There was one example of recordings being made in a manager’s communication book but not in the service users records. Duplication of information should be kept to a minimum. One of the three service users files checked did not contain a photograph of the service user. Three service users medication and medication administration sheets were checked. There was a system in place for booking medication into the home and for recording administration. There was however an example of medication not being booked in, in line with the procedures. Observations were made of the interaction between service users and staff. Staff were attentive to service users , approached them with sensitivity and were able to verbalise how on a daily basis they respected service users rights. Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 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): 12, 13, 14 & 15. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. There was a range of activities. These provided stimulation and pastimes for service users. Family and friend were able to visit and were encouraged to keep in touch with the service user. Service users were helped and encouraged to exercise control over their lives. A varied menu was available. EVIDENCE: There was a written programme of activity, service users were observed taking part in quizzes and games on the day of the inspection. Staff were designated to carry out the activities and service users said they enjoyed what was available. Records were kept of activities provided and the service users who had taken part. Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 Page 13 Staff were observed explaining the activities, how long they would take and after the activity, told the time and how long it was to lunch. They were given a choice about what to do next. They were asked if they wanted to sit quietly or if they wanted some music. Those that responded said they would like some music and a member of staff came and played the organ. Service users interacted by shouting out who they thought had sung the old songs that were being played . It was very pleasing to observe as both staff and service users were relaxed and quite spontaneous. Visitors were seen and were observed talking to staff and being made welcome. Although this is a home for people living with dementia, staff were seen encouraging service users to make choices about the meal they preferred , where they wanted to sit and what activities they wanted to take part in. This ensured that as much as possible service users were able to exercise some control over their lives. The inspector observed one service user ask a member of staff “what time is it”?. Instead of the member of staff just simply telling the service user the time he showed the service user his watch and the service user read the time and repeated it for himself. This promoted the service users independence and encouraged orientation. Lunch was observed. Service users were given a choice, the atmosphere in the dining room was relaxed and was not rushed. Service users said they enjoyed the meals that were provided. One service user who said he did not want anything to eat was offered lots of alternatives but ultimately his choice not to have anything was respected. Records were kept in service users files of food provided. Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 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 & 18. Quality in this outcome area was poor. This judgement has been made using available evidence, including a visit to the home. There is a procedure in place for investigating complaints. There had been no complaints made to the home since the last inspection. There was a procedure in place for responding to issues of adult protection and responding to allegations of abuse. There was however evidence to show that these procedures were not always followed. EVIDENCE: A record of complaints is kept and includes details of the investigation and of any action taken. There have been no complaints since the last inspection. There were two incidents recorded, detailing an assault on a service users by another service user. These incidents, had not been reported to the social services adult protection team or to the Commission For Social care Inspection. (CSCI) The service users notes lacked any follow up information and what action needed to be taken to reduce the risk of harm. The Manager was required to make retrospective notifications to the adult protection team and to the CSCI. Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 Page 15 There was one report of unexplained injury to a service user. A body chart was completed, this showed were the injuries were. The date and the person who found them were also recorded. There was no evidence to show any investigation into what had happened, how the service user could have got these injuries, and no record of observations in the following days. Staff said apart from recording their findings they were not aware of any other procedures to follow in the event of unexplained injuries to service users. Bole Hill View DS0000067344.V312244.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): 19 & 26. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. In the main the environment was safe well maintained, pleasant and hygienic. This ensured that service users lived in comfortable environment. EVIDENCE: Sufficient numbers of staff were employed to maintain the cleanliness of the home. Staff raised concerns about some of the carpets. There have been some concerns about mysterious stains appearing on the carpets that were new some fifteen months ago. They also expressed their view that carpets in the bedrooms and in the dining area, was impractical. They found it difficult to keep them clean and some bedroom carpets had been removed due to the level of incontinence. Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 Page 17 While in the main the home was pleasant bright and airy, a slight smell of urine was noted in two service users bedrooms and stains were noted on corridor, lounge and dining room carpets. Windows in the lounge and corridor area were open at the start of the inspection. These areas felt cold and service users said they were cold. The windows were closed immediately and the areas warmed up very quickly. Headboards were missing in two of the bedrooms. The manager said that problems had been identified with the quality of the furniture (which is relatively new) and this was being addressed with the supplier. Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 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, 28, 29 & 30. Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. The number and skill mix of the staff did not always meet Service users needs. In the main staff received the training they needed to carry out their duties and to support service users. Service users were protected by the homes recruitment policy and practices. EVIDENCE: There was a rota that showed the number of staff on duty. Staff said in there view there was not always enough staff on duty and staff often had to leave the care home to provide staffing and escort duty for the day centre. This was not an issue on the day of the inspection and during the previous week as the homes occupancy was very low and the day centre was closed. The majority of staff had achieved a National Vocational Qualification in care at level 2 or above. Staff said supervision sessions were improving and they were able to identify training needs. Some staff felt that due to poor staffing levels they were unable to put into practice some of their learning. Staff said that due to the increased levels of agitation and dependency of the service users being referred to them they felt they needed further training on managing challenging behaviour and how to defuse situations. Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 Page 19 Three staff files were checked and they contained all the information required by the Regulations and standards. Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 Page 20 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 was good. This judgement has been made using available evidence, including a visit to the home. There have been some changes to the management at the home this has caused some uncertainty and instability. Monitoring visits are made to the home and action taken to make sure that the home is run in the best interest of the service users. In the main service users financial interest were safeguarded. Staff received appropriate levels of supervision. There were many ways in which the service users health safety and welfare was promoted. There were however some issues regarding this. Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 Page 21 EVIDENCE: Since the last inspection the provider has changed to the Primary Care Trust. Staff were still trying to adjust to different ways of working as part of a new organisation. The registered manager who has managed the service for many years has been absent from the home for some months. Coming on top of the change organisation this has resulted in some instability and standard of management. The responsible individual said that action was being taken to ensure stability in the management team is addressed, make sure that the home is appropriately managed. The responsible individual makes regular visits to the home. A designated person makes reports on the conduct of the home. These reports includes (wherever possible) the views of service users, relatives and the staff. Records were kept of service users finances income and expenditure. Receipts were available for inspection and cash balanced with the account sheets. There was one example where it was not clear from the records that a service users account was in debit. There had been some gaps in the provision of supervision. The staff spoken to said this had improved. Supervision notes were noted on staff files. These however were not always signed and dated. Staff said they were always given a copy of their supervision notes. A fire door leading from the lounge, which had a self-closing device fitted, was noted to have an easy chair wedged in front of it. Should there have been a fire this would have prevented the door from closing. The manager pointed out that one of the fire doors on the corridor was extremely heavy and was always closed at night. This door is also fitted with a self-closing device and would close automatically should there be a fire. Staff found this door difficult to negotiate. The manager voiced her suspicion that she suspected it was possible that some of the unexplained bruising to service users could be as a result of them trying to negotiate this fire door during the night. The manager was required to carry out an immediate risk assessment, consult with the fire service and take the appropriate action needed to ensure the safety of the service users and staff. Service users files were not stored securely. Bathroom water temperatures were not being checked regularly. The manager said the gas system had been checked. The gas certificate seen at the time of the inspection was out of date. The pedal bin in the kitchen was broken. Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 Page 22 The majority of the staff team had not received fire instruction during the last six months. The manager was issued with an immediate requirement for all staff to receive instruction during their next shift on duty. A timescale of 12/10/06 was attached to this requirement. Staff spoken to said service users needs were changing and there were more requiring moving and handling intervention. Staff felt that an assessment needed to be completed to identify the need for additional moving and handling equipment. Bole Hill View DS0000067344.V312244.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 x 2 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 2 3 2 1 Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP2 OP3 Regulation 14 14 Requirement The service user or their representative must sign contacts. Appropriate action must be taken to ensure that the assessments received prior to admission to the home accurately all service users needs. Procedures must be in place to ensure that the staff have access to appropriate support when crisis situations arise which place service users at risk. Service users and their representatives must be assured (as much as is possible) that the home can meet the service users assessed needs. Care plans must detail who has contributed to the care plan. Falls assessments must be singed and dated. Each service user file must contain a photograph. Records must be kept of service DS0000067344.V312244.R01.S.doc Timescale for action 10/11/06 10/11/06 3 OP3 14 10/11/06 4 OP3 14 10/11/06 5 6 OP7 OP7 15 15 10/11/06 10/11/06 7 8 OP7 OP7 15 15 10/11/06 10/11/06 Page 25 Bole Hill View Version 5.2 users weight on admission and throughout their stay at the home. 9 OP7 15 Details of accidents must be 10/11/06 recorded in the service user daily notes. The notes must include information of the accident and any follow up action. Accident forms must only record details of one person, where a second service user has been involved in incident information must be recoded on a separate form with reference made to any corresponding information. To be found elsewhere. Care plans must include what action staff should take when faced with challenging behaviour including aggression and violence. Care plans must detail the action required by staff to meet service users needs. All care plans must be reviewed monthly. Procedures must be in place and monitored to ensure the safe recording ,storage and administration of medication. Therefore details of medication received, the date, the quantity Na the person booking the medication in must be recorded. Where information is transferred from the medication container to the administration sheet, this must be done in full. All staff must be reminded of what constitutes abuse. All DS0000067344.V312244.R01.S.doc 10 OP7 15 10/11/06 11 OP7 15 10/11/06 12 13 OP7 OP9 15 13 10/11/06 01/11/06 14 OP9 13 01/11/06 15 OP18 13 01/11/06 Page 26 Bole Hill View Version 5.2 incidents of abuse must be reported to the social services adult protection team and notified under regulation 37 to the Commission For Social Care Inspection. Those incidents referred to in this report must be reported in retrospect. The incidents of abuse, in the assault of one service user by another must be closely monitored and appropriate action taken to reduce the risk in the first instance. It is possible that they’re maybe a link between the increase in these incidents and the admission of service users who may in the past have been admitted to a more specialist service in addition to insufficient information available at the time of admission. This must be monitored, reported back to the Primary Care Trust and action taken as appropriate, to ensure the health safety and welfare of service users and staff. There must be a clear procedure in place, detailing the action to take in the event of discovering an unexplained injury to a service user. The temperature in all parts of the home must be maintained at a minimum of 21°c. The missing headboards must be replaced. All floor coverings must be adequately maintained, clean and in good condition. All areas of the home must be free from offensive odour. There must be at all times DS0000067344.V312244.R01.S.doc 16 OP18 13 01/11/06 17 OP18 13 01/11/06 18 19 20 OP19 OP19 OP26 23 23 26 01/11/06 20/11/06 10/11/06 21 OP27 18 01/11/06 Page 27 Bole Hill View Version 5.2 sufficient staff to meet the needs of the service users and to provide appropriate levels of supervision. The staffing numbers for the daycentre and for escort duty must be over and above that required for the care home. Consideration must be given to staff comments about training regarding managing challenging behaviour, and action taken to ensure that they are confident and competent in this area. The home must be run by a person who is fit to be in charge and able to discharge their responsibilities responsibly. To allow a clear audit trail, accurate and up to date records must be kept of service users finances income and expenditure. Service users files must be stored securely. Fire doors must not be held open by anything other that the automatic closing devices. In line with the homes policy bathroom water temperatures must be checked and recorded weekly. All staff that have not received fire instruction in the last six months, must do so during their next shift on duty. 22 OP30 18 10/11/06 23 OP31 8 10/11/06 24 OP35 17 01/11/06 25 26 27 OP37 OP38 OP38 17 23 23 01/11/06 03/10/06 01/11/06 28 OP38 23 12/10/06 29 OP38 23 Confirmation that this has been completed must be submitted to the commission For Social Care Inspection. A risk assessment must be 03/10/06 completed for the very heavy fire door. Consultations should take place with the fire service and action taken to reduce the risk of accidents to service users and DS0000067344.V312244.R01.S.doc Version 5.2 Page 28 Bole Hill View staff. A copy of the risk assessment including details of the action taken must be submitted to the Commission For Social Care Inspection. The pedal bin in the kitchen must be replaced. A current Gas safety certificate must be obtained and available for inspection. An assessment must be made to establish any need for additional moving and handling equipment. Where assessed as necessary this must be provided. 30 31 32 OP38 OP38 OP38 23 23 23 10/11/06 10/11/06 10/11/06 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 OP7 Good Practice Recommendations To reduce the risk of omissions and confusion the duplication of information. Unless absolutely necessary should be kept to a minimum. Bole Hill View DS0000067344.V312244.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Bole Hill View DS0000067344.V312244.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. 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!