Inspection on 20/10/08 for Bournbrook Manor

This inspection was carried out on 20th October 2008.

CSCI found this care home to be providing an Adequate service.

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

Bournbrook Manor 03/06/08

Bournbrook Manor 04/12/07

Bournbrook Manor 12/06/07

Bournbrook Manor 28/06/06

Bournbrook Manor 24/01/06

Bournbrook Manor 07/07/05

Bournbrook Manor 23/02/05

Bournbrook Manor 19/08/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

CARE HOMES FOR OLDER PEOPLE Bournbrook Manor 134a Bournbrook Road Selly Park Birmingham West Midlands B29 7DD Lead Inspector Jill Brown Unannounced Inspection 11:10 20th October,7 November & 4 December 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 Bournbrook Manor DS0000017006.V373061.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. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bournbrook Manor Address 134a Bournbrook Road Selly Park Birmingham West Midlands B29 7DD 0121 472 3581 0121 472 3581 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) Mr Rajen Odedra Usha Odedra Miss Tracey Leanne Harper Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP) 19 The maximum number of service users who can be accommodated is: 19 3rd June 2008 Date of last inspection Brief Description of the Service: Bournbrook Manor is located in a residential area of Selly Park in South Birmingham. The home is a large detached property, which offers care to nineteen elderly people. It is well situated and gives easy access to public transport and local amenities including shops, churches and park. Accommodation is offered over two floors with 15 single and 2 double bedrooms. All but one of the bedrooms have en-suite toilet and wash hand basins, two of the bedrooms also have an en-suite shower facility. The home has a shaft lift and a stair lift (although this is rarely used) giving easy access to the first floor for those with mobility difficulties. There is an assisted shower room on the first floor and a large assisted bathroom on the ground floor, which is also equipped with a shower. There are adequate toilet facilities throughout. Communal areas comprise of two large lounges and a dining room. There is parking space on the road to the front of the home. To the rear is a well-maintained garden with decking and garden furniture. The home’s fees were not discussed at this inspection but fees are available on request. There is a charge for hairdresser and chiropody services that visit the home. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We have visited the home on five occasions since the last key inspection in June. The home did not know we would visit on all these occasions. The first two visits were to look at issues raised at the last key inspection. The last three occasions looked at all of the key standards and monitored the homes compliance with outstanding concerns. This formed the key inspection and took place over about 17 hours. Information about all these visits is contained in this report. During the key inspection three people’s admission to the home was looked at and three people’s care was case tracked. This case tracking involved looking at all the records and information about these people, looking at their medication and their rooms and observing their care. This assists us to make a judgement about the care given. There are people accommodated at this home that have communication difficulties and it was not possible to fully ascertain their views of the service they receive. We did however speak to a number of people during our visit and observed them for signs of wellbeing. Other documentation about the running of this home was examined and a tour of parts of the building was undertaken. Medication administration was looked at. What the service does well: The home’s environment is good. People have well decorated, furnished rooms that meet their needs. Visitors and professionals are made welcome when they visit the home. People had access to health professionals when needed. Staff interactions with people were good and people were helped to undertake tasks in a kind and friendly way. People in this home have the choice where to receive their care and can spend times in their rooms. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 6 The management of peoples money is good and this protects people from abuse. The management of maintenance of gas electrical and fire safety was good and this protects people living in the home. What has improved since the last inspection? What they could do better: Managers need to ensure that before people are admitted they are aware what that person’s medication is for. This is so if the person has a specific health conditions such as mental health issues or behaviour due to dementia, the home can decide whether this is the most appropriate placement. They can also be aware of signs that show that the person’s health or behaviour is beginning to or likely to deteriorate. We have been taking enforcement action with this service since the last key inspection because of the management of risks to people such as nutrition, Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 7 falls and behaviour and in addition inappropriate moving and handling and staffing levels. Whilst for individuals identified at inspection this has now improved the management has not shown that they identify these issues all individuals with similar needs before inspection. This means that some people can experience delays in improvements to the way the personal and health care is delivered to them. Some elements of care that have improved have the potential to deteriorate because procedures are not always adhered to such as photocopying of prescriptions and checking that all medication is received and documenting when food has been offered. Concerns that are raised with the home are not recorded in the complaints record and this means that recurring themes are not sorted out. The manager and area manager working as care staff have improved staffing levels however this has meant the management roles have not been sufficiently covered to make the improvements needed. We have asked the service provider to review the care they provide people and to give us a copy of the documentation of this review with an improvement plan that will ensure sustained improvements. 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. The summary of this inspection report can be made available in other formats on request. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information is collected about people before admission and this assists the home decide the care the person needs. EVIDENCE: We looked at the admission process for three people admitted into the home since the last key inspection. The first persons admission details were looked at during a visit in August and two more during this key inspection. We found over this time there was a substantial improvement in ensuring that good information was collected. The home was improving in ensuring that information was collected before or at the point of admission and this is important as it helps ensure that people get appropriate care. Details were collected about a persons health and care needs, medication, lifestyle and risks to them. This means that the home can plan to meet the persons needs and minimise the risks from when they arrive. We found, for Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 10 example, a persons allergies to certain medication were recorded on the file, in the medication record and in the residents room. This ensures that the risks of that person are minimised. A number of records showed that people had no mental health or behavioural difficulties, however they were taking medication associated with these conditions. There needs to be some clarification of why these medications are being taken before admission to ensure that the placement is appropriate. Information about peoples lifestyles such as food choices, wanting to remain in their rooms to receive care, and what people could do for themselves were recorded and this helps to maintain peoples independence. Not all people admitted to the home have a preadmission assessment visit; these are recommended as they help to ensure that people make the right decision about being admitted to the home. The home has no male carers and this means that male residents do not have the option of assistance from a person of the same gender. Peoples religious beliefs and practices are recorded on care files and efforts are made to ensure that people can follow their chosen beliefs. The staff group reflects the cultural diversity of the people living in the home. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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. There are now systems in place to identify and monitor peoples health and wellbeing however is a lack of management of changes in people’s health and well being so people do not always get the needs met in a timely way. EVIDENCE: Care planning has improved since the last key inspection. Gaps and shortfalls in planning have had to be raised with the providers of this service at visits between these two key inspections. There had been a number of concerns about planning for people at risk of developing pressure areas, who are at nutritional risk or, who need assistance to move from place to place. An urgent requirement letter and a warning letter has been sent about these issues. There were improvements in planning for the people identified at inspections. Care plans were developing well with more information about how the person liked their care delivered and this helps to improve peoples happiness with the service. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 12 For example although people are now being weighed routinely, what people are eating is now being recorded and information about a persons nutritional needs are being kept in the kitchen; there was no planning for new people who were developing nutritional problems. This means that there could be delays in referrals to GPs, dieticians and so on and this may affect the well-being of these people. Records of food eaten didn’t include breakfasts and this could change a view about whether a person had appropriate levels of food. Instructions about how to manage peoples nutritional needs are not always recorded in a way to ensure that the information can be found easily. The home has set up charts of fluid and food intake of people at risk and this helps to ensure that any difficulties in these areas can be reported quickly to health professionals. We found that the home had set up a short-term care plans for people where needed including one for catheter care. We had been concerned about the moving and handling of people and the equipment used. We gave the home a legal notice to improve. As a result two new hoists and slings have been purchased and staff have been trained in their use. Information about who is to use a particular hoists and slings is attached to the hoists. We have since seen some very good interactions between staff and people being moved. A concern was raised with us about a person not being moved regularly who was at risk of pressure sores. However we found that the home had improved in this area and were assisting people to move to prevent pressure areas developing. In previous months we were concerned about the management of identified risks to people. However we saw an improvement in the management of this over the visits since the last key inspection. For example we had found a poor risk assessment for the use of bedrails and badly fitting of bedrails, which put a person at risk. This has now been rectified. Records of district nurses did not indicate that they had any concerns. People do have access to health professionals when changes in health care are identified. There are records of people having contact with chiropodists; district nurses GPs and other health professionals. We noted in one record that staff had been shown how to check a piece of equipment every three days however this requirement was not recorded in the care plan. This means that this check may be missed and could affect the care of the person. The recording of accidents had improved; this should ensure that any specific risks to people can be acted upon. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 13 We looked at the medication administration on a number of visits and this showed the medication was administered as prescribed with few discrepancies. All previous requirements had been met at the key inspection. However on the last visit, the home had received a monthly supply of medication and copies of the repeat prescriptions were not available. One person’s Medication Administration Record (MAR) did not contain a prescribed food supplement, which the daily records indicated was being given, and had been prescribed the previous month. A medication that was to be administered once a month did not have indicated on the MAR the day it should be administered. A medication had been prescribed on a short term basis but information from the daily records and the MAR did not match. These shortfalls could mean that people do not get the medication prescribed, or are given medication wrongly. Medication administered by the district nurses were not shown on the medication administration record. The management of the administration of medication needs to follow the home’s procedure. We observed good interactions between people living in the home and staff. People were assisted to maintain a good presentation by staff helping them to change clothing if anything got spilled and this helps them to keep a good view of themselves. A person said “its ok here, I’m 85 got my own room, go out a lot by myself, foods ok, everybody different, sometimes its not what I like but can ask for something different”. We noted at one of our visits that a person was being disturbed by the positions of the photocopier and the hoist and as a result arrangements were made to move the lounge furniture around to make this disturbance less likely. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 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. 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. People in this home are able to make choices about their care, activities and meals and this improves their life. A wider range of activities including some that are accessible to people with dementia would enhance their lives further. EVIDENCE: People have choices about how and where their care is given. A number of people choose to stay in their rooms watching their TVs and so on. Those people who can self-motivate activities are encouraged to do so. Whilst visiting it was noted that people spend their time listening to appropriate music and playing bingo. Some people went out with families. People with dementia need further efforts to engage them in more person centred activities. The availability of carers and the care needs of some of the people in the home have impacted on the amount of activities that are available. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 15 There are no restrictions on visiting times. Visitors to the home have been made welcome. Theres been an improvement in the kitchen facilities in the home, which enables food to be stored more appropriately. There was a good amount of food stored and available. People were offered a choice of food at the main meals. Some people had to go a long time between the last meal of the day and breakfast and this was discussed with the management, especially for people who are of low weight. As reported in health and personal care section this has improved for people at risk but needs to be considered for all people living in the home. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 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. 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. Although the home has taken steps to improve the information it gathers about dissatisfactions these are not in place enough to improve the service for people. Although there processes in place to ensure that people are not put at risk by intentional harm there needs to more management of care practices to ensure that people remain well. EVIDENCE: A complaint record is held in the home. Despite being aware of concerns and issues that have been raised these were not recorded in the complaints log. People are encouraged to fill in surveys with their key workers however the format of these is not suitable for all people to complete and do not empower people to affect the way the home is run. This means there isnt management oversight of concerns in a way that assists them to make improvements. The home has recently made available the comments book in the reception area of the home. There are two good comments about the care people are receiving in the home. We had concerns about staffs understanding of how they safeguard people from abuse. Training has now been given and copies of appropriate policies and procedures are in place. Concerns were raised with us about the homes Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 17 practice about nutrition and assistance to prevent pressure areas and these have been raised with the social services department. These concerns are listed in the health and personal care and management and administration sections. The staff have the appropriate safeguarding checks before working in the home. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment of the home provides a safe and comfortable place for people to live. EVIDENCE: We looked around the communal areas, bathrooms and sampled a number of bedrooms in the home in August and found the following. The home was generally well maintained clean, fresh and tidy. People have two lounges, which they can use during the day if they wish and there is a large dining area. There is a passenger lift available from the ground to the first floor. The layout of the building generally meets the needs of the people living there. This was also found when we visited the home subsequently. A number of peoples rooms had new carpets. On the last day of the key inspection we found that the home was suitably decorated for Christmas. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 19 The home has now had its kitchen refurbished and this helps food to be stored appropriately. We advised that the home obtain a copy of the Department of Health’s guidance ‘Infection Control guidelines for Care Homes’ as this gives instructions to promote good infection control. This has now been done. The staff talked to found that the increase in staffing in the morning had improved their ability to ensure people received care in a timely way and allowed some time for the routine cleaning of the home. The home has a cleaner but they have not been at work for some time. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 20 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. 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 staffing levels are not always enough to meet the needs of people in the way that people would wish. The recruitment of staff could be improved to ensure that people can be assured that thorough checks are being done. Staff receive awareness training in most of the areas needed however there is need to ensure some in depth training about conditions that people have. EVIDENCE: We found that the home did not have enough staff to ensure that the needs of people were met at all times during the day and an urgent requirement was made. The numbers of staff on duty was increased to ensure that people could be assisted to get up in the morning and have their breakfast at a reasonable time. However the numbers of staff assisting people was only increased by the managers working as care staff. This has had an effect on the management of quality within the home. (See Management and Administration section). The home has two thirds of staff that have completed an NVQ2 in care and this means that staff are aware of the care needs of older people. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 21 We had concerns about whether or not the recruitment of staff was a robust enough to ensure the safety of people living in the home. We look at the records of the newest member of staff and found that checks had been made with the criminal records bureau and the protection of vulnerable adults (PoVA) list. Staff employed with only a PoVA check must work under supervision and have a risk assessment and records about interview questions would make the process more robust. . Training was available to staff; we found that some training had been undertaken and some was planned. Recent training had been given in fire safety, food hygiene, moving and handling, infection control, health and safety and safeguarding. Dementia care awareness training was planned and first aid training was still required. Whilst the mandatory training was almost complete the management will need to consider the number of first aiders available to meet their legal obligations and more in-depth dementia training. There was no record of how the trainers were appropriately qualified to train staff in mandatory training. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,28 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in this home do not have a service that can respond to the changes in their care needs quickly or manages their concerns in a way that helps them have a voice in how the home is run. The environment and peoples money is managed well and this gives people security. EVIDENCE: The manager of this home has yet to complete a registered managers award (RMA) and we have advised they look to complete the new qualification in leadership and management of care services. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 23 We have found a lack of identification of risks to people living in the home, shortfalls in service and a lack of planning for future improvement. Inspection is relied upon to identify shortfalls. Actions to rectify the shortfalls identified sometimes take too long. While some attempts are being made to gain peoples views of the service this is not done in an enabling way. It is also hard to determine where people’s views have resulted in improvements. The management do not record dissatisfactions in a way that would be useful to them, and have not looked at issues raised such as nutrition and skincare for all people when issues of risk for a particular people have been raised. There have been sustained improvements in the recording and management of residents’ money. We found appropriate systems of detailed records and receipts and this ensures the residents’ money is safe. We found that the home had appropriate certificates in place to confirm that fire, gas and electrical safety inspections and maintenance had been undertaken. This ensures that people have a safe place to live. Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 3 2 N/A 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 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement Copies of prescriptions must be kept and must be checked against previous and current Medication Administration Record to ensure that it is correct and no medication has been missed. You should designate the day on the Medication Administration Record the day when a monthly medication is to be given. There must be an accurate record for medications administered on a short term basis so this is auditable. Where people raise issues about the service a record should be kept so as to ensure that the home can improve The registered people must ensure that systems are in place to ensure that risks to people living in the home are identified and actions taken to minimise those risks. The registered people must ensure that the home is run in a way to promote and make DS0000017006.V373061.R01.S.doc Timescale for action 20/12/08 2 OP16 22 31/12/08 3 OP31 13(4)(6) 31/12/08 4 OP31 12 (1) 31/12/08 Bournbrook Manor Version 5.2 Page 26 proper provision for the Health and welfare of the people living there. 5 OP33 24 The registered people must have a system for routine review of the service they provide to improve their service. A review of their service must be available to commission in addition to an improvement plan 31/01/09 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 OP1 OP2 OP3 Good Practice Recommendations The statement purpose must be reviewed to ensure that it contains accurate information about the service. Not inspected on this occasion A record should be kept of when relatives or people living in the home have been given a copy of their contract. Not inspected on this occasion Where people are on medication that can be used to manage a persons behaviour some clarification should be sought before they are admitted so appropriate planning can take place People should wherever possible visit the home before admission this is to ensure that they have a choice about whether they are admitted and that the home suits them. Records of food eaten should include breakfasts and where a person refuses food this should be recorded. Information about nutrition should be kept together in the care plan. Where instructions have been given by health professionals on the management of care or equipment are given this should be recorded in the care plan. It is recommended that all prescribed medication is recorded on the medicine administration record chart including medicines administered by external healthcare professionals. Not met on this occasion DS0000017006.V373061.R01.S.doc Version 5.2 Page 27 4 5 OP5 OP8 6 7 OP8 OP9 Bournbrook Manor 8 9 OP12 OP16 10 11 12 13 14 OP19 OP29 OP30 OP31 OP33 A range of activities must be provided to meet the needs of all the people in the care home. Not met on this occasion Complaints procedures should be in a format that makes it easy for residents to raise concerns or make comments on the service provided. Outstanding since 31/12/07 Office equipment should not be sited in residents communal areas. Records of recruitment interviews should be kept to ensure that gaps in employment, staff understanding of care can be tested. The management should assure itself that trainers are qualified to undertake the training in mandatory areas such as moving and handling The manager must complete the Registered Managers Award or equivalent. Outstanding since the June 2006 The home should improve the ways they collect residents views to improve the service and this should result in an annual report. Outstanding June 2006 Bournbrook Manor DS0000017006.V373061.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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