Inspection on 24/01/06 for Bournbrook Manor

This inspection was carried out on 24th January 2006.

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

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

Other inspections for this house

Bournbrook Manor 20/10/08

Bournbrook Manor 03/06/08

Bournbrook Manor 04/12/07

Bournbrook Manor 12/06/07

Bournbrook Manor 28/06/06

Bournbrook Manor 07/07/05

Bournbrook Manor 23/02/05

Bournbrook Manor 19/08/04

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Heathlands

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Breme

Ravenhurst

Bank House

Inspirations

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

CARE HOMES FOR OLDER PEOPLE Bournbrook Manor 134a Bournbrook Road Selly Park Birmingham West Midlands B29 7DD Lead Inspector Brenda O`Neill Unannounced Inspection 09:30 24 January 2006 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.V269101.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 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 Tracey Harper (Acting) Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mrs Odedra must provide evidence of completion of the Registered Managers Award or equivalent by April 2005. 7th July 2005 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 a patio area and garden furniture. Access to the lawned area of the garden is problematic from the rear of the home as there are several steps to negotiate. There is alternative access to the garden by a side exit of the home. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in January 2006. This was the second of the two statutory visits for the home for 2005/2006. To get a full overview of all the standards assessed this report should be read in conjunction with the report made following the inspection on July 7th 2005. During this visit a partial tour of the premises was made, two resident and two staff files were sampled as well as other care and health and safety records. The inspector spoke with the acting manager, one of the proprietors, briefly to two staff on duty and four of the eighteen residents. What the service does well: What has improved since the last inspection? The recruitment procedures for new staff had improved with the majority of the required checks being undertaken prior to staff commencing their employment. The acting manager had successfully recruited bank staff which helped ensure the staffing levels could be kept to an acceptable level. The CSCI was being appropriately notified of any accidents or incidents in the home ensuring the correct procedures were followed and giving the inspector an ongoing overview of what was taking place in the home. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 6 The safety and comfort of the residents had been improved with the fitting of thermostatic mixer valves to the wash hand basin, some new bedroom carpets had been fitted and some new bedroom furniture had been purchased. The inspector was also informed that new lounge chairs and dining room furniture were on order. 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. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 There was information available for prospective residents about the facilities and services available in the home enabling an informed decision about admission to be made. Copies of the social worker’s assessments were not being obtained when necessary therefore staff did not know the needs of the residents at the pre-admission visit. EVIDENCE: The statement of purpose and service user guide for the home were viewed at the last inspection and found to include all the relevant information however they both needed updating to reflect the current staffing in the home. The inspector was informed that this had not been addressed. The file for the most recent admission to the home was sampled. There was evidence that the individual had visited the home prior to admission and that during this visit the staff at the home carried out an assessment. The home’s assessment covered all the required areas. There was also evidence that there had been social work involvement in the admission as there was a copy of an initial care plan drawn up them. This gave very little information in relation to the individual’s needs or background. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 9 The acting manager needed to ensure she obtained a copy of the social worker’s assessment prior to admission of any residents so that the individual needs were known as in this case there were some family issues that the staff at the home were not aware of and were now attempting to manage. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 Care plans needed to reflect the current needs of the residents and include details of how staff were to meet these. Risk assessments needed to be undertaken for all residents to ensure any identified risks were minimised. Residents were being put at risk by the handling methods used in the home. Improvements were needed to the medication system to ensure residents received all their medication at the prescribed times. EVIDENCE: Two care plans were sampled, one for a new admission to the home and one for an individual who had been resident for some time. One of the care plans gave a lot of detail of the individual and what assistance was needed from staff and what she was able to do for herself. The care plan covered a variety of areas including personal care, mobility, relationships and diet. It was noted that on the care plan it stated ‘likes all food’ but on the daily records a little after admission it stated ‘quite a few dislikes in food’ however the care plan had not been updated. There was no evidence to suggest that the individual had been consulted about the care plan. The second care plan sampled gave some very good detail of the individual needs of the resident however they did not reflect the current needs. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 11 The monthly reviews written by staff clearly detailed changes and deterioration both physically and mentally but the care plan had not been updated. The acting manager needed to ensure that all the care plans are updated as the needs of the residents change. Neither of the files sampled included any personal risk assessments and it was evident from discussions with the manager and the daily records that these were necessary. There was clear evidence of challenging behaviour and of issues involving a relative that needed to be risk assessed and have clear management guidelines in place for staff to follow. Only one of the two files sampled had manual handling risk assessments. During the course of the inspection one of the residents fell and he was lifted from the floor by two staff which could have caused injury to both the resident and staff. The manual handling risk assessment for the individual clearly stated that if they fell the hoist was to be used. This was of concern to the inspector as not only did this go against the risk assessment but also would not have been a handling method that was compliant with the Manual Handling Regulations or training. Both files sampled had nutritional and tissue viability screenings. The documents for one of the residents were correctly completed and had been reviewed. Where a risk had been identified a management plan had been put in place. For the other resident, when staff had completed the assessments not all areas had been taken into consideration and for the tissue viability assessment had this been done correctly would have put the resident into a risk category. The daily records sampled were very repetitive and gave little information about the care that had been given to the residents. It was also a concern to note such statements as ‘funny mood’, ‘aggressive’, ‘being a nuisance to others’ with no further information or clarification. Staff must ensure they write what they see or hear not their interpretation of situations that arise so that other staff reading the notes knew exactly what they meant. There was evidence on the files sampled of input from medical professionals as required including, district nurses, opticians, hospital admissions and more specialised help from psychiatric hospitals. The home continued to administer medication via a 28-day monitored dosage system. Several items of medication were not included in the monitored dosage system. An audit of these showed numerous discrepancies which clearly suggested that on numerous occasions staff were signing for medication and it was not being administered. The medication checked included every day medicines and also short courses of antibiotics. The manager needed to address this as a matter of urgency and undertake staff drug audits before and after drug rounds to determine their competence in drug administration. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 12 It was also noted that some eye drops were stored in the drug trolley that should have been stored in the fridge and none of the eye drops had been dated on opening. The controlled medication in the home was being stored and administered appropriately. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed during this inspection. There were two requirements made at the previous inspection one in relation to choices of meals for people on special diets which had been met, the other in relation to evidencing that residents social needs were being met in the daily records had not been met. This was evidenced by the poor and repetitive recording as mentioned earlier in this report. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The two core standards were not assessed during this visit but were assessed at the previous inspection. The requirement made at the previous inspection has been brought forward to this report. The manager stated the home had had no complaints since the last inspection and none had been lodged with the CSCI. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 15 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, 20, 21, 22, 24, 25, 26 The standard of the environment within this home is good providing residents with an attractive and homely place to live. EVIDENCE: There had been no changes to the layout of the home since the last inspection which was suitable for its stated purpose and generally well maintained. It was comfortable and homely with a good standard of furniture, fittings and décor. Since the last inspection seven bedrooms had had new carpet, two new beds and bedroom furniture had been purchased. The garden was well maintained and attractive however, it was accessed via the back door by means of steps which was problematic for some of the residents. Residents unable to manage the steps could access the garden by going out of the front door and around the side of the home. A ramp had been investigated but found to be unsuitable. Some minor repairs and maintenance were needed in the kitchen, for example, a knob on the hot plate and a handle on the grill pan needed replacing and the grouting between the tiles particularly on the windowsill needed renewing. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 16 The outstanding requirement made by the environmental health officer in relation to the ventilation in the kitchen had been addressed and a new industrial extraction unit had been installed. Communal space was adequate in the home with two large lounges and a dining room. These were generally well furnished and decorated, however, as at the last inspection some of the armchairs were looking worn and needed to be replaced. The inspector was informed that new armchairs and dining room furniture were on order. There were adequate bathing and toileting facilities in the home some large enough to allow for full assistance from staff. The ground floor bathroom was not inspected during this visit but the inspector was informed no changes had been made. This room was very institutional in appearance and would benefit from redecoration to make it homely. The sluice that was located in this bathroom had been boxed in however it was recommended that it was removed. All but one of the bedrooms had en-suite toilets and wash hand basins and two had an en-suite shower. The inspector was informed that all hot water outlets to the wash hand basins had had thermostatic mixer valves fitted since the last inspection. The aids and adaptations available appeared to meet the needs of the residents and included, a shaft lift, emergency call system and hand and grab rails. The hoist was still being stored in the lounge which was not appropriate. All the bedrooms inspected varied in size, were comfortably furnished and well decorated with a good standard of furniture and fittings. Some of the bedroom carpets had been replaced since the last inspection. The manager had discussed with the residents their requirements in relation to bedroom furnishings and records of their requirements were on their personal files. All bedrooms had a lockable facility and thumbnail locks to the doors. These locks enabled residents to lock their doors when inside and were accessible to staff however the residents would not be able to lock their doors easily when they left their rooms. On the day of the inspection the home was found to be clean and odour free. Protective clothing was available for staff when necessary. There was a system for the disposal of clinical waste. The laundry was appropriately located and equipped. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 17 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, 29 Adequate staffing levels were being maintained to meet the needs of the residents. Recruitment procedures were robust and ensured the protection of the residents. EVIDENCE: The home retained a core group of staff that had worked at the home for a considerable amount of time and there had been little staff turnover since the last inspection. The acting manager had managed to recruit some bank staff which had enabled her to keep staffing levels to three staff until 7pm and two after this until 10pm when the night staff began their shift. These levels appeared to meet the needs of the residents. The home also employed a cook. There were very friendly relationships evident between the staff and residents and the residents spoken with were very positive in their comments about the staff team. The recruitment records for two staff recently employed were sampled. The majority of the required documentation was available including, completed application forms, two references, POVA first checks and medical declarations. It was necessary for the acting manager to ensure that all staff were eligible to work in this country prior to employment. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 18 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, 38 The manager ensured the smooth running of the home in a competent manner. An application for the registration of the manager needed to be forwarded to the CSCI so that residents were assured someone was responsible and accountable for the running of the home. The health and safety of the staff and residents was well maintained. EVIDENCE: The acting manager had been employed at the home since March 2005 however an application for her registration by the CSCI had not been received. The proprietor of the home needed to ensure that an application was submitted as a matter of urgency and an immediate requirement was left at the home to this effect. The acting manager demonstrated a good knowledge of the residents in her care and the running of a residential home. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 19 The acting manager was aware that she needed to be qualified to NVQ level 4 in management and care and was pursuing this. There were good relationships evident between the manager, residents and the staff team. Health and safety were well maintained and staff had received training in safe working practices. The acting manager was reminded that staff fire training must be updated every six months not yearly. There was evidence on site of the required checks being made on the fire system. There was evidence on site of all equipment having been serviced and that the water system had been checked for the prevention of legionella. The building was well maintained. There were thorough premises risk assessments and documented evidence that senior staff did walk the building regularly to specifically look for any risks and then ensured these were addressed. The recording of accidents was appropriate and notifications to the CSCI had improved since the last inspection. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 20 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 2 X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 2 3 2 X 3 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 2 Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 21 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 OP1 Regulation 6(a) Requirement The statement of purpose and service user guide must be updated to reflect the current staffing in the home. Previous time scale of 01/09/05 not met. The terms and conditions of residence must include the number of the room to be occupied and the correct address of where to refer complaints. Previous time scale of 01/09/05 not assessed for compliance at this visit. The manager must ensure that a copy of the social workers assessment is obtained prior to admission of any residents where applicable. Previous time scale of 01/09/05 not met. All residents must have care plans that detail all their current needs in respect of health and welfare and how these are to be met by care staff. Care plans must be regularly updated as the needs of the Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 22 Timescale for action 01/03/06 2. OP2 5(1)(b) 01/03/06 3. OP3 14(1)(b) 01/03/06 4. OP7 15(1) 01/04/06 residents change. There must be evidence that wherever possible the residents have been consulted about the care plans. Previous time scale of 14/08/05 not met. All residents must have personal risk assessments undertaken to minimise any identified risks. There must be clear guidelines for staff to follow for the management of any challenging behaviours. All residents must have manual handling risk assessments. Previous time scales of 01/05/05 and 14/08/05 not met. All staff must follow the manual risk assessments that are in place for residents. The manager must ensure that all staff adhere to the Manual Handling Regulations. The manager must ensure that any nutritional or tissue viability screenings are completed correctly to reflect the current needs of the residents. Daily records must clearly detail the welfare of the residents so that situations cannot be misinterpreted. The amount of medication remaining in containers must correspond with the amounts received into the home and those administered. Any discrepancies must be investigated. Previous time scale of 15/07/05 not met. Regular staff drug audits must be undertaken to ensure the Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 23 5. OP7 13(4)(c) 01/03/06 6. OP7 13(5) 01/03/06 7. OP7 13(5) 10/02/06 8. OP8 12(1)(a) 01/03/06 9. OP8 12(1)(a) 01/03/06 10. OP9 13(2) 31/01/06 competency of staff in handling medication. Previous time scale of 14/08/05 not met. All eye drops must be dated on opening and discarded after 28 days. Eye drops must be stored as per the manufacturers instructions. Staff must record how residents are spending their days and the activities on offer to evidence their social needs are being met. Previous time scale of 14/08/05 not met. There must be a record in the home of any complaints made by residents or their representatives or staff about the operation of the home to include any investigations and outcomes. Previous time scale of 14/08/05 not assessed for compliance at this visit. The minor repairs and maintenance highlighted as needed during the inspection must be addressed. Any worn armchairs must be replaced. Previous time scales of 01/06/05 and 01/09/05 not met. Appropriate storage arrangements must be made for the hoist. Previous time scales of 01/05/05 and 01/09/05 not met. 50 of care staff must be qualified to NVQ level 2 or the equivalent. Previous time scale of 31/12/05 not assessed for compliance at this visit. The manager must ensure that staff are eligible to work in this country prior to employment. DS0000017006.V269101.R01.S.doc 11. OP12 12(1)(a) 01/03/06 12. OP16 17(2) 4 (11) 01/04/06 13. OP19 23(2)(b) (c) 16(2)(c) 01/04/06 14. OP20 01/03/06 15. OP22 23(2)(l) 01/04/06 16. OP28 18(1)(a) 01/04/06 17. OP29 19(b)(i) 01/03/06 Bournbrook Manor Version 5.0 Page 24 18. OP30 18(1)(a) Induction for new staff must be facilitated by senior staff. Ancillary staff must undertake induction training. Previous time scale of 01/09/05 not assessed for compliance at this visit. Induction training must be crossreferenced to the guidelines laid down by Skills for Care to ensure all the required areas are covered. Previous time scale of 01/04/05 not met. Time scale of 01/10/05 not assessed for compliance at this visit. An application for the registration of the manager must be forwarded to the CSCI. Previous time scale of 01/09/05 not met. The manager of the home must be qualified to NVQ level 4 in management and care or the equivalent. The registered person must ensure that effective quality assurance and quality monitoring systems are in place. Previous time scale of 01/05/05 not met. Time scale of 01/10/05 not assessed for compliance at this visit. Where joint receipts are issued for expenditure made on behalf of residents these must be adequately detailed and signed to ensure they cannot be altered at a later date. Previous time scale of 01/09/05 not assessed for compliance at this visit. All care staff must receive a minimum of six supervision sessions per year. Previous time scale of 01/09/05 not assessed for compliance at DS0000017006.V269101.R01.S.doc 01/03/06 19. OP30 18(1)(a) 01/04/06 20. OP31 8(1)(2) 31/01/06 21. OP31 9(2)(b)(i) 01/12/06 22. OP33 24(1)(a) (b) 01/04/06 23. OP35 17(2) 4(9)(a) 01/03/06 24. OP36 18(2) 01/04/06 Bournbrook Manor Version 5.0 Page 25 25. OP38 23(4)(d) this visit. Fire training must be updated every six months. 01/04/06 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. Refer to Standard OP21 OP21 Good Practice Recommendations It is strongly recommended that the ground floor bathroom be redecorated to make it more domestic in character. It is strongly recommended that the sluice facility is removed from the ground floor bathroom. Bournbrook Manor DS0000017006.V269101.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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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