CARE HOMES FOR OLDER PEOPLE
Bournbrook Manor 134a Bournbrook Road Selly Park Birmingham West Midlands B29 7DD Lead Inspector
Jill Brown Unannounced Inspection 28th June 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bournbrook Manor DS0000017006.V301120.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.V301120.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 F/P 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.V301120.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Old age not falling into any other category (19). That the manager completes the Registered Managers Award by 30 April 2007 and a copy of the certificate be sent to the Commission. 24th January 2006 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. The home stated that there current fee level is £314.00 for a shared room and £346.00 for a single they did not disclose their top up charges. Bournbrook Manor DS0000017006.V301120.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An unannounced visit to Bournbrook Manor took place in June over nine and a half hours. During this visit the inspector looked at care records of 3 residents in detail and 3 staff records. Medication Administration Records were looked at against the medication held in the home. Accident and complaint records were seen and a number of maintenance and inspection records of the building and services such as services and so on. During the inspection 8 residents were spoken with as well as one member of staff other than manager and owner. A tour of the building was undertaken. At the time of the inspection all of the residents were from a white UK ethnic background and spoke English as their first language. What the service does well:
Residents were happy with the service the home provided and said that the staff were ‘obliging.’ One resident said that she spends time in her room but staff always come and check on her. Another resident said it was ‘a good decision to come here.’ Residents appeared well cared for and had attention to their personal hygiene needs. The home collects good information on residents and this includes information about likes and dislikes and this helps ensure that residents are happy in the home. The home makes arrangements for residents’ religious needs to be met and at times gives residents that wish individual time to practice their beliefs. It was clear that residents that had a tendency to fall had risk assessments in place and the homes accident records showed that residents did not fall excessively. The home responded well to any residents that said they had pain and showed an appropriate understanding of the urgency of this. The arrangements for visitors and choice were good residents said they were able to get up when they wanted and go to bed when they wanted. Bournbrook Manor DS0000017006.V301120.R01.S.doc Version 5.2 Page 6 The homes environment was homely and welcoming for example the dining room tables were set with tablecloths, condiments, and flowers, and the bedrooms were well decorated and reflected the individual resident’s taste. Residents thought the food was reasonable especially breakfasts. The home was clean and fresh on the day of the inspection and had an appropriate level of staff. The home did not have complaints and the residents were kept safe by the policies and procedures the home had. Residents’ money was well managed and good records were kept. The home was generally well managed by a management team that were clear about where they need to go to continue to improve. The home has begun its quality assurance process and this should result in a yearly report. What has improved since the last inspection? What they could do better:
The home needs to ensure that complete a number areas of risk assessment better especially about nutrition and smoking as these inform the staff how to make residents safe. A number of needs did not have adequate care plans when the needs were raised. For example there was a resident that had a history of not eating well and was of low weight but there was no nutritional plan. A number of care plans did not have the level of detail required such as size of slings to be used with the hoist and this could put residents at risk. The home needed to not only monitor residents’ weights but also have a system to ensure that action could be taken were needed. This includes more detailed recording of what residents eat. Residents that have difficulty managing feeding themselves should be offered adapted equipment such as plate guards large handled cutlery and so on. The home also could consider residents serving themselves vegetables from tureens. Care plans needed to be updated and reviewed in a number of cases.
Bournbrook Manor DS0000017006.V301120.R01.S.doc Version 5.2 Page 7 A number of improvements was needed in medication administration to ensure that all staff were carrying out this task appropriately. Whilst activities were available and the home needs to ensure that residents that are not able to join group activities have an individual plan about they have one to one time with staff. Whilst the areas within the home that the residents have access to were homely areas such as the kitchens, the garden, storage areas for staff belongings resident records and for equipment needed improvement. A bathroom needed improvement to enable residents to have a fully accessible bath if they wished. The rota produced of staff working need to show who was in charge when the manger was not on duty to ensure that fire procedures or other emergency could be carried out well. The home needed to ensure that residents’ views were captured at the time they made them and this could assist in the home making further improvements. The home needed both to improve on its training and show clearly there current performance level for the staff team. Whilst staff were appropriately checked with the Criminal Records Bureau and PoVA before starting work the home needed to ensure that the staff continued to have the ability to work in country when the agreement lapsed. The home must advise the Commission of any event that affect the resident. 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.V301120.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.V301120.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes arrangements for giving and collecting information were adequate improvements were needed to ensure that residents are accurately informed and risks to residents are minimised. EVIDENCE: The home supplied the Commission with updated versions of their Statement of Purpose and Service User Guide before the report was undertaken. The home has ensured that details of the manager have been updated. The staffing information could be clearer about training numbers and experience of staff for relatives and residents to know what they can expect in terms of staffing levels. The Service User guide needs to be consistent in the information that it provides about the Commission.
Bournbrook Manor DS0000017006.V301120.R01.S.doc Version 5.2 Page 10 Residents in the home have a contract these need to be reviewed to ensure that fee levels are accurate and information given as to when fee levels are reviewed. The home collects useful information about residents before they are admitted into the home. In addition to collecting information on medical conditions and personal care needs such as ‘allergic to penicillin’ and ‘needs encouragement to dress,’ the home also collects information about how residents like their care to be given for example likes a night time drink before bed at 10.30 pm. There was evidence the home were asking social workers for copies of their assessment where these had been done so that they were able to meet residents’ needs more appropriately. A number of risk assessments were not adequate including one for a resident that smokes; more detail was needed of the amount of restriction the home were placing on smoking and safeguards that were in place. Assessments of risks and nutrition were absent or in a number of cases poorly completed. The home at the time of the inspection had residents only from white UK background that were either practising or non- practising Christians. Church services are held at the home. During the inspection one resident had parts of the bible read out to her by a member of care staff as this was something she liked. The home assesses residents’ communication needs and it was clear they understood the need for structured communication for people with dementia. It was clear that the home does undertake pre admission assessments. Bournbrook Manor DS0000017006.V301120.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 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 this service. Although the care provided was good, care plans and medication administration were variable and this could lead to inconsistencies and put residents at risk. EVIDENCE: Care plans were not in place for some of the needs identified in residents’ assessments. For a resident that needed to be checked three hourly on a night by their assessment did not have this shown on their care plan. Residents that were said to be poor at eating did not have a nutritional plan. Care plans did not have enough detail on how their needs were to be met for example how aggression was to be managed, type of slings used when hoisting an individual resident and personal care. Care plans were reviewed monthly but there was not enough space to record whether any changes to the plan were needed. Bournbrook Manor DS0000017006.V301120.R01.S.doc Version 5.2 Page 12 The home were considering changing the care plans but they must ensure that any replacement allows care staff to get key information quickly and is able to be used as a working tool in giving care to residents. Residents’ weights were taken but it was not clear at what point any weight loss or gain would be referred to the manager and whether this would result in a change in the plan. Records showed residents weights as ‘normal’ without a clear chart showing that a residents weight was within recommended guidelines. Records of food eaten were not in enough detail to ensure that on inspection they showed that the resident was having enough nutrition in amount and type of food taken. Although it showed clearly what choices residents had made. The home’s records of accidents showed that residents were not falling excessively and fall risk assessments were completed. Residents personal hygiene needs were attended to, residents appeared well care for. A medication audit was completed and found that the management of medicinal creams was poor with many creams being open for a long time and potential to cause micro-bacterial infection one being prescribed in 2005. One resident with dementia was prescribed a medication that was not recommended with one of the resident’s conditions and this must be checked with the prescribing GP. Medications not in the monitored dosage system that were checked was found to have been signed as administered but had not always been given. The manager of the home was undertaking audits of amounts of medication but needed to under take audits of staff competency. The home had appropriately transferred information from the assessment to the Medication Administration Record where needed such as allergic to penicillin. A resident that expressed that they had pain was attended to directly. The homes medicinal fridge was not having recorded the maximum, minimum and current temperature to ensure that medication was being stored to the manufacturers instruction. It was also recommended that it be recorded on the Medication Administration Record when liquid medication is opened. Staff were observed to treat residents appropriately and with respect. One resident said that the staff were ‘obliging.’ One resident said that she spends time in her room but staff always come and check on her. Another resident said it was ‘a good decision to come here.’ Bournbrook Manor DS0000017006.V301120.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. The home were making appropriate arrangements for activities and meals but need to consider how they respond to individual residents needs and maintain independence. The arrangements for visiting and choice were appropriate. EVIDENCE: A number of the residents in the home were able to organise activities for themselves and these residents were seen reading, watching television in their room and going out. A number of residents attend day centres. Residents with dementia did not have an individual structured activity plan that included one to one time with staff. However staff were recording activities that residents enjoyed in daily records and this was an improvement on previous inspections. Residents appeared to be able to visit when they wanted and were seen visiting relatives in the lounges. It was clear that residents were able to spend time in their room if they wanted residents said that they were able to get up when they wanted and go to bed when they wanted. There was evidence of this information being
Bournbrook Manor DS0000017006.V301120.R01.S.doc Version 5.2 Page 14 collected at the assessment stage. Individual residents were having breakfast at 10am and residents said they were able to have a cooked breakfast if they wished. Meals were provided in two dining areas. The tables were well set out with table clothes, condiments and flowers. Meals were plated and the choice of meal for the day was sausages or chicken and mushroom pie. The inspector tried the latter and this was tasty and well prepared. Residents said the food was generally good but several made comments about the sausages, which they thought were not good and had tough skins, and beef burgers were not liked. Residents when asked did not appear to know what was for dinner or pudding and menus at the table may assist with this. A number of the residents were quite able and consideration of the use of tureens for self-service would perhaps increase the amount of conversation at the table. Drinks were available at the table. The inspector saw one resident struggling in cutting up their food and suggested that large handled knife and fork may assist and was told that this was provided for them at the day centre. Bournbrook Manor DS0000017006.V301120.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. The home has processes and procedures in place that protect residents. EVIDENCE: The Commission have had no complaints since the last inspection. The home states they have had no complaints. The home as a complaints procedure that meets the requirements but ensure that the Commissions details are the same on each version. Residents said they had no complaints other than the small issues raised previously. The home needs to look how they encourage residents’ comments and how they record these to further improve the service. All staff have had a Protection of Vulnerable Adult check as a minimum before employment and Criminal Record Bureau checks are routinely applied for. The home has appropriate adult protection procedures. The home has had no incidents of an adult protection nature since the last inspection. Bournbrook Manor DS0000017006.V301120.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): 19,20, 21,22,24 & 26 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. Whilst the areas used by residents were pleasant and attractively furnished the kitchen, and staff areas needed to be refurbished and reorganised to ensure a hygienic environment. EVIDENCE: The home was clean and fresh on the day of the inspection and generally well maintained. The building appeared homely and the home had recently bought some new chairs. The home should consider when replacing any more the heights of the residents to ensure that there are a range of chairs that residents can choose. The home was building some offices in the garden and although this may assist the organisation further work was needed to make the garden accessible and a pleasant are for all residents to use. The garden was accessed via the
Bournbrook Manor DS0000017006.V301120.R01.S.doc Version 5.2 Page 17 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 but this was curtailed by the building work. The home did not inform the Commission about this building work. The home’s kitchen was extremely hot on the day of inspection before cooking started. The ventilation was inadequate. The units were looking tired and some edges of shelving were compacted board and unable to be adequately cleaned. The fridge temperatures recorded were higher than the 0-5 degree centigrade recommended to prevent bacteria growth. The home does not have a dishwasher and for the number of residents this is recommended. A bathroom in the home had not been refurbished as recommended at the previous inspection and contains a manual sluice that is not recommended by Health Promotion Agency. The owners provided the Commission of minimal details of proposed works to rectify these areas but these are not in enough detail for the inspector to monitor progress. The home still wishes to retain the manual sluice and not upgrade the bathroom to provide a full assisted bathing area. The home is proposing an upgrade of the kitchen within 12 months and the garden area within 6 months including improving the access for residents. The home had appropriate aid and adaptations for residents but had no storage space for the hoist and wheelchairs. The hoist was kept in the lounge and wheelchairs were being stored in the laundry. Residents were moved appropriately and had items such as spectacles and hearing aids in place. Residents’ bedrooms were clean and furnished to a high quality. Residents’ had brought in their belongings and these were very personalised. A number of bedrooms have en suites and some have showers. A number of ventilation units were not working well. Communal bathing and toilet facilities had liquid hand wash and paper towels available. The laundry had staff uniforms hung up and staff belongings were kept in staff toilet these arrangements must be reviewed to ensure security of staff belongs and good infection control practices. The home has a sluice washing machine and tumble dry facilities. Bournbrook Manor DS0000017006.V301120.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 this service. The home generally recruits staff in appropriate way but must ensure that staff continue to have the ability to work in the UK. Induction, mandatory and NVQ 2 training in care levels needed to be improved and records organised so these can be scrutinised to show that staff have the skills needed to meet residents need. EVIDENCE: At the time of the inspection there appeared to be enough staff to provide the care for the residents. The home provided four weeks staffing rotas. The rotas did not show who was in charge of the home when the manager was not present or any management hours when the manager was off sick. The home currently provides three carers for the morning shift and two for the afternoon and a cook between 8-30 and 1pm and 3 or 4 and 7pm. The manager stated that 5 out of the current 15 care staff have the NVQ 2 in care and this puts them below the 50 required at 30 . A number of staff are currently undertaking the course. The inspector checked the Criminal Record Bureau checks for all the staff in the home. The vast majority of these were in place. A number had been employed following a Protection of Vulnerable Adult check only and this was
Bournbrook Manor DS0000017006.V301120.R01.S.doc Version 5.2 Page 19 acceptable. One staff member needed to update their evidence for being able to work in the UK. The training records were not clear that staff were meeting the Skills for Care induction requirements or the mandatory training requirement and a matrix of staff attendance at training was requested. Bournbrook Manor DS0000017006.V301120.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 this service. The home has clear management processes and the procedures in place protect residents. The home could make further improvements in resident consultation and showing how they have acted on this. EVIDENCE: The manager of the home has become the registered manager since the last inspection and as part of her registration has to completed the registered managers award by 30 April 2007. The home has begun a quality assurance system but the results of this are not yet in place an annual report of the outcome of consultations and audit of service will need to be produced and be available on request. Two residents
Bournbrook Manor DS0000017006.V301120.R01.S.doc Version 5.2 Page 21 meetings had been held in the last six months. Discussion was had with the manager about different ways of gaining residents’ views. Staff meetings have also been held and these showed that areas of practice were discussed and clear instructions given. The provided ensures that independent visits are carried out a monthly basis to look at quality issues. Residents that were assisted to with personal allowance had their money recorded appropriately. The money checked was accurate with the recorded balance. The home registered no concern about residents’ access to money. Staff were receiving regular supervision and this was recorded in their files. It was clear that the manager was on target for staff to receive supervision 6 times a year and this was an improvement. This gives staff an opportunity to raise concerns in practice as well as for the manager to set good practice targets. Care plans were stored in a locked facility in the kitchen. This is not an adequate place to store as it encourages staff to enter the kitchen after giving personal care and interferes with the cook’s area. The home had started building in the garden of the home and this was not reported to the Commission. The home must advise the Commission of any event that affect the residents as in this it curtailed residents access to the garden. The home ensures that routine maintenance and inspection of services such as gas and electric, wheel chairs and lifting equipment and has an appropriate level of liability insurance. The inspector was unable to find where all staff had training in fire safety in the last 6 months. Bournbrook Manor DS0000017006.V301120.R01.S.doc Version 5.2 Page 22 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 2 2 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 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 3 17 X 18 3 2 2 2 3 X 3 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 2 3 Bournbrook Manor DS0000017006.V301120.R01.S.doc Version 5.2 Page 23 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 Timescale for action 30/09/06 2. OP2 5(1)(b) 3 OP3 13(4)(c) The statement purpose must contain information about the numbers of staff, their experience and qualifications The terms and conditions of 30/09/06 residence must be reviewed to ensure fee levels are accurate and that information is given on when fee levels are reviewed. a) Risk assessments for 31/08/06 residents that smoke must outline any restrictions on levels and places of smoking, patterns of smoking, and any actions staff must take to ensure the safety of the resident and the home. b) Residents must have risk assessments for all risks identified. a) 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. b) Care plans must be regularly updated as the needs of the residents change. 4. OP7 15(1) 31/08/06 Bournbrook Manor DS0000017006.V301120.R01.S.doc Version 5.2 Page 24 c) There must be evidence that wherever possible the residents have been consulted about the care plans. Previous time scale of 14/08/05 and 01/04/06 not met. 5 OP8 12(1)(a) 16(2)(i) a) The manager must ensure 31/08/06 that any nutritional or tissue viability screenings are completed correctly to reflect the current needs of the residents and where needed ensure a nutritional plan is place. b) Residents that have unplanned losses and gains in weight that cause concern must have a nutritional plan. c)The home must record the amount and type of food eaten by residents. a) 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 and 31/01/06 not met. b) Regular staff drug audits must be undertaken to ensure the competency of staff in handling medication. Previous time scale of 14/08/05 and 31/01/06 not met. c) All medicinal creams must be discarded within 28 days to prevent micro-bacterial contamination. d) The home must record the current, maximum and minimum
Bournbrook Manor DS0000017006.V301120.R01.S.doc Version 5.2 Page 25 6. OP9 13(2) 05/07/06 7. OP12 12(1)(a) 8. OP15 12(3), 23(2)(n) temperature of medicinal fridges to ensure medicines are kept within their product licenses. Residents that are unable to join group activities must have individual activity plan to show how they have one to one time with staff. a) The home must ensure they collect residents’ comments about food and show how they have acted on them. b) Residents must be given, where necessary appropriate aids to enable them to eat independently. The home must provide a detailed plan of the work on the kitchen area and the garden areas. Appropriate storage arrangements must be made for the hoist. Previous time scales of 01/05/05 01/09/05 and 01/04/06 not met. a) The home must provide appropriate storage facilities for staff belongings and uniforms. 31/08/06 31/08/06 9 OP19 23(1)(a) (2)(o) 23(2)(l) 31/08/06 10. OP22 30/09/06 11 OP26 23(3) 31/08/06 12 13. OP27 OP28 14. OP29 b) The home must ensure that the ventilation units shut off after an appropriate length of time. 23(4)(c)(ii The staff rota must show who is i) in charge of the building when the manager is not on duty. 18(1)(a) 50 of care staff must be qualified to NVQ level 2 or the equivalent. Previous time scale of 31/12/05 and 01/04/06 not met 19(b)(i) a) The manager must ensure that staff continue to remain eligible to work in this country. b) Evidence of the enhanced CRB disclosures for existing staff with 31/08/06 31/10/06 31/08/06 Bournbrook Manor DS0000017006.V301120.R01.S.doc Version 5.2 Page 26 15 OP30 18(1)(c) 16 OP31 10 (3) 17 OP38 23(4)(d) 18 OP38 37 PoVA checks only must be sent to the Commission. A matrix of dates all staff training in the mandatory courses must be sent to the Commission. The manager must complete the Registered Managers Award by 30 April 2007 and a copy of the certificate be sent to the Commission. Fire training must be updated every six months. This remained outstanding since 01/04/06 The home must advise the Commission of any event that affect the resident. 31/08/06 30/04/07 31/08/06 31/07/06 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 OP9 Good Practice Recommendations It is recommended that the home records when liquid medication is opened on the Medication Administration Record (MAR) and carried forward on the next MAR if still in use. It is recommended that residents that are able are encouraged to serve themselves food. It is recommended that menus be available on tables for residents to remind themselves of the choices for the day. 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. It is recommended that the home look at how they can improve the ways they collect residents views to improve the service.
DS0000017006.V301120.R01.S.doc Version 5.2 Page 27 2 OP15 3 4 5 OP21 OP21 OP33 Bournbrook Manor 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
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