Inspection on 03/06/08 for Bournbrook Manor

This inspection was carried out on 3rd June 2008.

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

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 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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Bournbrook Manor 134a Bournbrook Road Selly Park Birmingham West Midlands B29 7DD Lead Inspector Jill Brown Key Unannounced Inspection 3rd June 2008 09:00 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.V366438.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.V366438.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.V366438.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. 4th December 2007 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’s fees were not discussed at this inspection. The home has a hairdresser that calls and they charge £6.50 for a shampoo and set, £5.00 for a trim, £21.00 for a perm and £16.00 for a tint these are subject to review. Bournbrook Manor DS0000017006.V366438.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 0 star. This means the people who use this service experience poor quality outcomes. We visited the home on a day in June to carry out an inspection. The home did not know we would visit. A key inspection was undertaken which looked at all of the key standards. The inspection took place over about 9 and half hours. Since the last key inspection we have visited once to ensure that medication administration was safe. There was also a thematic inspection in May 2008 that looked at how people living in the home were safeguarded. The report will include all these visits. Services are required to complete an Annual Quality Assurance Assessment (AQAA) on a yearly basis; this was required from the home before this inspection and information from this was used in this report. During the visit in June 2008 three people’s needs were case tracked. This case tracking involved looking at all the records and information about these peoples, looking at their medication and their rooms and observing their care. This assists us to make a judgement about the care given. We also looked at part of another person’s care notes. 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 four of the peoples on this visit and three relatives. We received a further 6 comment cards. 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 contacts health professionals when a person’s health deteriorates or causes concern. People living in the home know the names of the people that care for them and say that the staff are kind and helpful. Staff assisted people to move from place to place well; they gave clear instructions about how the person could help in moving. Medication administration remained improved. Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 6 People’s visitors were made welcome and could see their relative or friend in private if they wished. The areas where people live in the building are well maintained and decorated and meets the needs of the people living in the home. What has improved since the last inspection? What they could do better: The information that is available to people deciding whether to come into this home needs to more accurately match the service delivered so that people can make a decision whether this home will suit them. A record of when people coming into the home or their relative are given information and a copy of the contract needs be made. This is to ensure that the home can show that people have their rights maintained. There needs to be timely risk assessments where risks are known this is to ensure that wherever possible these risks are minimised and people are enabled to carry out their life safely. This includes risk of falling, weight loss and nutrition, skin care and lifting equipment use. Care plans need to show how people’s diversity needs are met including cultural, religious and disability. Details on peoples care plans were not always in place in practice when checked against daily records such as glasses. Comment cards received and people spoken to suggest that the range of activities and food could be improved to enhance people’s lives. People’s meal provision did not always meet the individual person’s nutritional needs. At the thematic inspection it was found that there were not procedures in place to safeguard people from abuse, staff did not have a good understanding of these and there had been no training. At this inspection although the procedures had been brought in there had been no training for staff and no attempt to share procedures with them. We made some urgent requirements for this to be attended to. Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 7 The kitchen area needed to be refurbished to ensure that food could be stored and prepared safely. Staffing levels did not mean that staff could ensure that activities were done routinely and that deep cleaning was undertaken. There was additional pressure when the cook was not working. The management of people’s money was not safe or robust and some practises were not acceptable for example using peoples money for shortfalls in petty cash or change. We found there was inadequate auditing of the policies, procedures and the paperwork ensuring people’s care. 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.V366438.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.V366438.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): 1,2 3 &4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information available does not always reflect the service and this could mean that people are not able to make an informed choice. Information is collected about people before admission and this assists the home decide the care the person needs. EVIDENCE: The home had available in reception a copy of the Statement of purpose and service user guides and a brochure devised by the previous owners was available on request. The statement of purpose and service user guide needed to be updated to accurately reflect the service now on offer. For example people living in the home no longer have access to a cordless phone for calls they may wish to make and there is no longer a smoking area in the home. Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 10 There were copies of individual contracts with people and these contained the amount people needed to pay and where need the amount of the top up charged if people were part funded by social services. There was no record of when a copy of this contract was given to the person living in the home or their representative. Information was collected on a person’s health and social needs before they were admitted to the home. This assists the carers to develop plans of how the person’s needs can be met. People are offered an opportunity to come into the home for a day to see if the home will suit them and if the home can meet the care needs the person has. The home has staff from a diverse ethnic background and this assists people from these cultures. Bournbrook Manor DS0000017006.V366438.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. Care planning and risk assessments were not sufficient to ensure that all peoples were cared for appropriately and not put at risk. People had consultations with health professionals and had their medication administered appropriately and this assisted in keeping people well. EVIDENCE: We looked at the care records, plans and risk assessments for three people and found a number of shortfalls. A recent admission in the home did not have sufficient plans or risk assessments to meet their needs and this potentially puts them at risk. Another person had a risk assessment that stated they had the potential to develop pressure areas without a plan to minimise this. Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 12 A number of people had diabetes and did not have enough in their plan about signs that would indicate ill health. One person’s plan did not ensure that their diet was controlled and behaviour managed to maintain their health. Although information about peoples ethnic background, religion and culture were collected this did not result in these needs necessarily being planned for or met. Some people had plans to maintain good moving and handling practice others did not. People were observed to be transferred from place to place in a sensitive way with good instructions given so people could assist themselves. We found that in one situation where moving and handling equipment was not sufficiently reliable for the moving of a person from place to place. There was some good personal details on some care plans such as likes to wear watch on their left wrist, wears glasses and the specific ways that staff can assist a person with communication needs. On most of the care plans there are records of discussion with peoples about whether they prefer male or female carers. Records and comment cards showed that people are referred to health professionals when needed. We looked at the medication administration and found that people received their medication as prescribed. On one person’s records the amounts of medication brought into the home had not been recorded and this made accounting for the medication difficult. Two people did not always sign in medication and this could lead to errors not being identified. The temperature medication is stored at still needs review and records of temperature taken at the peak time of the day. Observations of staff interacting with people living in the home showed that people were listened to and care given well. People thought the staff were kind and clearly knew the staff well that cared for them. The thematic inspection found that people were happy with the care they received. Bournbrook Manor DS0000017006.V366438.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14 &15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The activities available met the needs and expectations of some people but not all. This means that some people have little to enhance their life from day to day. People are able to have visitors when they wish and to move freely within the home and this gives purpose to the day. Whilst adequate amounts of food are given this is not always matched to the nutritional needs of people and this can impact on their health and well being. EVIDENCE: The record of activities in the home stopped in mid May and it was commented on that staff hadn’t had time to undertake activities recently. A family member commented about their attempts to try and to get outings for the people living in the home over the last 12 months there is now one planned. Assessments were containing information about the activities people enjoyed before admission and care plans had actions in them of how to continue this. Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 14 Records show that all the people living in the home were involved in an exercise once a month with external provider, and over the last 2 months a video afternoon and a fashion evening. The other times table top games including cards, bingo, puzzles and word searches and chats with people or making fairy cakes were done either individually or in small groups. Some people had activities regularly others did not. A number of people had a walk to the park. The majority of the time people watch television. We did not find a budget dedicated to the provision of activities. Comment cards from relatives and people living at the home. Comment cards received said that people in the home usually or sometimes get their activity needs met. Relatives spoken to thought and comment cards said that they could visit when they wished and that staff were good. Relatives said that the home would contact them if there was a change in the persons health condition. Relatives were seen visiting either with the person in their bedroom or in the main lounges. People were allowed to spend time in their rooms and were able to walk around the building. The home has an enclosed garden to the rear of the building. Individuality in food choices was not always available and a person’s nutritional plans were not adapted to meet an emerging health and behavioural need. In the morning there was a variety of cooked breakfasts on offer for the people as well as cereals tea and toast. This was a topic of conversation for two people in the small lounge about what was on offer. People spoke of their enjoyment of this meal. The menus provided did not show the full range of food on offer snacks were not included. People in the small lounge did not receive a snack mid morning however the majority of people were eating their breakfast on arrival and did not finish until just before 9 am. Comment cards suggested and discussion with people found that the food provided was usually good. A person commented that the food was basic but ok. Bournbrook Manor DS0000017006.V366438.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is now a complaint process in place that should enable people to receive a response to the concerns that they raise. This should improve the service to people living in the home. The understanding, practises, policies and processes are not in place to ensure that people are safeguarded in the home. EVIDENCE: We made requirements for there to be a record of complaints and concerns raised with the home by December 2007. We were told that this was put in place in April 2008 when a complaint was received about cleaning of the home. We also received information about this on a comment card sent to us as part of the information gathering before inspection. We looked at the outcome of this complaint and found that there was a plan to recruit a cleaner. We saw evidence of an application for this post. We recommended the home devise a more accessible complaint procedure for people that have some cognitive impairment. A pictorial complaints procedure had been started but this did not adequately signpost people to how to make a complaint. We have received no complaints about the home. Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 16 A thematic inspection was undertaken in May and this found that the home had shortfalls in information available to staff, staffs understanding and training on abuse and safeguarding of people. However that staff were recruited properly, but processes could be improved further (see standard 29) and this helps to maintain the safety of people. On this inspection a copy of the multi-agency guidelines were in place, there had been no organisation of training or discussion with staff about the guidelines received. We looked at the financial management of people’s money and found this was not managed safely. (See Standard 35) We were concerned about the reliability of the moving and handling equipment (see Standard 8) Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. The areas where people live in the building are well maintained and decorated and meets the needs of the people living in the home. The kitchen area needs improvement to ensure that food can be stored and prepared in hygienic environment. EVIDENCE: We looked around the communal areas, bathrooms and sampled a number of bedrooms in the home and found the following. The home was generally well maintained clean 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. Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 18 One of the shared rooms is currently being used as a single room and the home has only one other shared room. All but one bedroom has en suite facilities. The downstairs bathroom has been redecorated to make it more homely to use. A number of carpets have bee renewed. People living in the home were happy with the environment and thought that the home was comfortable. A concern was raised about the cleanliness, the lack of dedicated staff to cleaning means that the deep cleaning of bedrooms, kitchens and bathrooms is hard to achieve. Although the home appeared clean and fresh certain areas needed attention. The kitchen area remains hot and in need of refurbishment and this is planned in the next few weeks. The fridges in the kitchen cannot be kept at a suitable temperature through out the day and were found to be keeping food too warm at this inspection. We have been advised the kitchen is to be refurbished in the next few weeks. The equipment in the laundry was suitable for purpose and good infection control measures were in place to manage laundry. Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 19 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 social care needs of people and cleaning needs in the home and this can mean this can adversely affect the people living in the home. The recruitment of staff is safe and this protects people. Staff receive training in areas in most of the areas needed however there are some significant gaps which could affect the care of people. EVIDENCE: Comment cards received suggest that there are not always enough staff to provide the care for the people’s needs in the home. Activities are not always provided and cleaning time can be inadequate. The rotas provided showed that the manager worked Monday to Friday and was on call for alternative weeks. The deputy was on call for the other weeks. It was not clear who was undertaking the cooking when the cook was not on duty for example at the weekends and when they were on annual leave. And staffing levels were not always adequate to cover these tasks. Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 20 We found that the manager was counted in the care numbers although she stated that dedicated management time had now been given. 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. A the thematic inspection it was found that staff were recruited appropriately and that required checks by the Criminal Records Bureau, Protection of Vulnerable Adult (PoVA) Lists, references and so were undertaken before a person was recruited to the staff team. They found further improvements could be made by the manager gaining a copy of the PoVA guidance and by requiring explanations for any gaps in employment. The manager had gained the PoVA guidance as requested. We were provided with a training matrix and this showed that the majority of staff had undertaken mandatory training and some of this was due for renewal in August 2008. Some staff new staff needed to complete this. The manager has got a copy of the common induction standards to complete with new staff. This was in process at the time of the inspection. The manager stated that some specialist training had taken place about for example stoma care but this was not recorded and no certificates seen. Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 21 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): 31,33,35,37.38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management of the home does not show that it is run in the best interest of the people living there. There are significant lacks in safeguarding, management of money and documentation to put people’s health and wellbeing at risk. EVIDENCE: The manager has worked in care of older people for a long time she has started her Registered Managers Award (this is due to finish in August 2008), which is the recognised training for this job. There were significant shortfalls in areas of safety for people that the manager had oversight of. These lacks were concerning. Immediate and urgent requirements were made to ensure that people living in the home were safeguarded (see standard 35 and standard Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 22 18). The manager had little say of the spending in the home to meet the needs of the people living there. There has been over recent months attempts to get the views of people about the service they provide. This had not been collated to look at improvements the home needs to make. There are visits to the home from representatives of the owners and this results in reports for improvements. There was no evidence of a plan for the improving the service in the home. The home supplied us with an annual quality assurance assessment as requested however this was minimally completed and did not show how the service intended to improve. We looked at two people’s money and found. There was little explanation on the record where incoming came from. Relatives were not given a receipt for money they give to the home for relative’s personal allowance and there was carbon copy so there is no audit trail of this. There was no record on what basis relatives or representatives were managing people’s money and this can cause difficulties. Receipts of spending were not in sufficient detail for example there was little information on hairdressing receipts about the person providing the service or the service given. In one case a receipt had the wrong date on it and this had not been seen when it was presented. There was no method of cross-referencing receipts with the record making auditing difficult. There were no records of audits of these records. The homes Annual Quality assurance Assessment stated that the home had a procedure for the management of peoples money but they were unable to produce this at the time or subsequently. In both money wallets there were scraps of paper with amounts of money recorded. We were told that this was to cover either shortfalls in petty cash to pay the entertainer or change to pay the hairdresser this is unacceptable. Money held did not match the record. Records generally needed to be improved. There were a number of errors in spelling the names of people living in the home for example; documentation not completed that means that mistakes can be made procedures and policies were not in place or inadequate to ensure the safety of people. There was no auditing of the information kept about people. We looked at he health and safety of the building records and found certificates in respect of Fire, electrical and gas safety were in place and this ensures that people have a safe building to live in. Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 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 2 17 X 18 1 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 1 X 1 3 Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 13(4)(c) Requirement When a risk is identified a plan must be developed to manage the risk. Timescale for action 30/06/08 2 OP7 15(1) 12(4)(b) This is to ensure that people at risk of: - falling, nutritionally, developing pressure areas or due to their behaviour have these risks minimised. Care plans must be written to 30/06/08 reflect the ethnic, cultural and religious diversity of the people in the homes care. This is to ensure that people have care that meet their individual needs. Lifting equipment must be assessed for its appropriateness for an identified person’s needs This is to ensure that the person is lifted safely and comfortably. You must ensure that an appropriate procedure is available for staff to follow on discovering abuse. You must ensure that staff are 3 OP8 13(4)(c) 30/06/08 4 OP18 13(6) 20/06/08 Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 25 aware of policies and procedures that safeguard residents from abuse. You must ensure that staff have training in protection of vulnerable people. An urgent requirement was sent to the provider. This is to ensure that where abuse is suspected appropriate action is taken. A review of the staffing levels 30/06/08 must be undertaken and suitable action taken to ensure that these meet the needs of the residents. A record must be kept of that review. This is to ensure that the staffing levels meet all the needs of people living in the home. Money held for residents must be auditable at all times. Money must not be taken out of residents’ accounts without a record being made. This is to ensure that residents are protected from financial abuse. 7 OP35 17(2)sch 4(9) 13(6) Outstanding since 31/12/07 You must devise a procedure 06/06/08 for the safe management of residents’ money and implement it. You must ensure that transactions of residents money have 2 signatures. Residents’ money must be used for only their expenses and not be used to fund group bills. Regular audits of residents’ DS0000017006.V366438.R01.S.doc Version 5.2 Page 26 5 OP27 18(1)(a) 6. OP35 17(2) Sch 4 (9) 06/06/08 Bournbrook Manor money must be undertaken and a record kept of this. Receipts of money spent on and received on residents behalf must contain enough detail to provide an audit trail. An immediate requirement was left at the home 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 4 Refer to Standard OP1 OP2 OP9 OP9 Good Practice Recommendations The statement purpose must be reviewed to ensure that it contains accurate information about the service. A record should be kept of when relatives or people living in the home have been given a copy of their contract. Two people should book in medication to ensure that the medication is accurate with the Medication Administration Record and the doctor’s prescription. A Review of the time the temperatures are taken in the lounge should be undertaken and temperature recorded. Action must be taken to store drugs elsewhere if the temperature exceeds 25 degrees Celsius. A range of activities must be provided to meet the needs of all the people in the care home. 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 A full assessment of the kitchen facilities must be undertaken and work carried out to improve facilities within a suitable time scale. It is recommended that the manager obtain a full employment history from new workers and provides a written explanation of any gaps in employment for that worker. DS0000017006.V366438.R01.S.doc Version 5.2 Page 27 5 6 OP12 OP16 7 OP19 8 OP29 Bournbrook Manor 9 10 11 OP31 OP33 OP37 The manager must complete the Registered Managers Award. The home should improve the ways they collect residents views to improve the service and this should result in an annual report. You should undertake routine reviews of documents policies and procedures to ensure their consistency and accuracy. Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands 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. Extracts may not be used or reproduced without the express permission of CSCI Bournbrook Manor DS0000017006.V366438.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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