Inspection on 07/07/05 for Bournbrook Manor

This inspection was carried out on 7th July 2005.

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 24/01/06

Bournbrook Manor 23/02/05

Bournbrook Manor 19/08/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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 B29 7DD Lead Inspector Brenda O Neill Announced 7 July 2005 th 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 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 E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bournbrook Manor Address 134a Bournbrook Road Selly Park Birmingham B29 7DD 0121 472 3581 0121 472 3581 Telephone number Fax number Email 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 Vacant. Care Home 19 Category(ies) of Old age, not falling within any other category. registration, with number (19) of places Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 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. Date of last inspection February 23rd 2005 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 E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection and was carried out over one day in July 2005. This was the first of the statutory inspections for this home for 2004/2005. Prior to the inspection the manager completed a pre-inspection questionnaire with a variety of information in relation to residents, staff and health and safety records and several comment cards were returned to the inspector. During the inspection a tour of the premises was made, three resident and three staff files were inspected as well as other care records and health and safety records. The inspector spoke with the manager, the proprietor, two senior carers, nine of the eighteen residents and one visitor. What the service does well: There were no rigid rules or routines in the home and all the residents spoken with were happy with the service they were receiving. Without exception all those spoken with were happy with the staff group stating they were ‘good’ and ‘kind and helpful’. Other comments received from residents, visitors and health care professionals included: ‘If you can’t be at home there’s no better place’ ‘Always made welcome no matter what time I visit.’ ‘If I buzz they are here in two or three minutes’. ‘Staff no problems’. ‘I have always found the staff very friendly and caring towards the . clients who all seem very happy.’ ‘Above average and very patient orientated’. The residents preferred daily routines were documented in their care plans and these were known by staff. There were individual diaries of medical attention for residents which demonstrated their health care needs were met. All residents spoken with were happy with the meals provided and there were choices available for most people. Meal times were flexible and residents could have their main meal in the evening if they wished and also breakfast in bed. There were monthly trips out and in house entertainers organised by the ‘The Friends of Bournbrook’. The home provided residents with a very comfortable, homely environment that was well maintained with a good standard of furnishings and fittings. Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3, 4 and 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 home had a statement of purpose and service user guide which included all the required information however both needed updating to reflect the current staffing in the home. Three residents files were sampled and all included signed and dated terms and conditions of residence. However the terms and conditions did not include the room numbers to be occupied and gave the incorrect address for referring complaints to. The files sampled included assessments undertaken by the home, two at the pre-view visit and the other at the hospital as this person was privately funded and had no social work involvement. The home’s assessment covered all the required areas. Where there had been social work involvement only the initial Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 Page 9 care plans drawn up by the social workers were on the files which gave very little detail of the individual needs of the prospective residents. The 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. All residents spoken with were happy that their needs were being met by the home. The practices observed throughout the inspection evidenced that staff were able to meet the needs of the residents for example, interactions with residents, appropriate terms of address, appropriate assistance with personal care and meals. There was documented evidence of access to health care professionals when needed, for instance chiropodist, doctors and district nurses. There was evidence in the home that aids had been obtained to assist with pressure care and continence management. There were aids and adaptations throughout the home to assist those with mobility difficulties, for example, shaft lift, assisted bathing and showering facilities. Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 and 10 The care planning system in the home was good but needed to ensure all the individual needs of the residents were included to ensure staff knew what needs had to be met. All residents needed manual handling risk assessments to ensure they were handled appropriately. The health care needs of the residents were being met. The medication system needed some improvements to ensure the residents were not put at risk and received their medication appropriately. EVIDENCE: Three care plans were sampled during the inspection. Two of these were detailed and informed staff of what the residents were able to do for themselves, what they needed help with and how this was to be given. The other did not include details of the individual’s personal care needs or if she was able to do anything for herself. All the care plans included good details of the residents’ preferred daily routines and of their likes and dislikes. The care plans were being reviewed monthly but there was no evidence that residents were consulted about their care plans. Only one of the files sampled included a manual handling risk assessment and this was detailed, however the manager needed to ensure that all residents had manual handling risk assessments. All the files sampled had detailed personal risk assessments, Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 Page 11 tissue viability assessments and nutritional screenings. Where any risks had been identified on the tissue viability assessments a plan had been put in place to minimise the risks. All files included a diary of medical attention which detailed visits to the residents from health care professionals including doctors, district nurses, chiropodists and opticians. There was detailed information on resident’s files about specific illnesses, for example, diabetes and how this displays when not controlled and what staff should do about it. Health care notes were sometimes difficult to track as they were not being dated, staff were writing the day and not the date and sheets were not numbered. Daily records must be dated to ensure staff can track them easily from one sheet to the next. There was a 28-day monitored dosage system in operation in the home and this was generally well managed. Only senior staff handled medication and most had had accredited training, others were undertaking it. There was appropriate storage of controlled medication and a controlled drug register on site and this was being used appropriately. The following requirements were made at this inspection: • All medication must be acknowledged as received from the pharmacist on the MAR sheets. • Copies of all prescriptions must be kept and cross-referenced to the medication received. • There must be a complete audit trail for all medication held in the home. • Tablets remaining in containers must correspond with the amounts received and administered. • The manager must undertake staff drug audits to ensure the competency of staff in handling medication. Visitors could be received in resident’s bedrooms or the dining room when not in use or the quieter lounge. During the inspection staff were observed to use appropriate terms of address when talking to residents and knocking on bedroom doors and waiting for permission to enter. Screening was provided in the double bedrooms to ensure the privacy of the occupants. Residents were able to lock their rooms when they were inside if they wished. Staff could open the locks in an emergency but they did not allow residents to lock their rooms easily when they left them. All bedrooms also had a lockable facility for the storage of personal effects. Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. There were no rigid rules or routines in the home and there appeared to be activities on offer however these did not meet with all resident’s expectations. The meals offered in the home were good with choices available the majority of the time but choices needed to be expanded for special diets. EVIDENCE: Residents spoken with confirmed there were no rigid rules or regulations and they could spend their time as they wished. Resident’s preferred routines were documented in their care plans. Residents were seen to wander freely around the home, spend time in their rooms, watch television, chat to each other and staff and receive visitors. Residents had mixed views about the activities on offer in the home some saying they got bored, as there was nothing to do and others being quite happy. It was difficult to determine what activities were offered as they were not reflected in the daily records. The manager stated the types of activities on offer were bingo, skittles, jigsaws and exercise. One of the residents went out independently and several others went out with families. There were monthly trips out organised by ‘The Friends of Bournbrook’ and occasional in house entertainers. There were regular church services and students from the local university visited the home one evening every week to do activities and chat to the residents. Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 Page 13 The residents appeared to be able to exercise personal autonomy and choice, for example, where and when they had their meals, when they got up and went to bed, how they spent their time and if they wanted to go out. Bedrooms were seen to be personalised to the occupants choosing. Visitors were seen to come and go from the home and appeared to be made welcome. The visitor spoken with stated he came late some evenings and this was never a problem for the staff and he was made welcome. All residents spoken with were happy with the catering arrangements at the home. The menus seen were varied and nutritious and residents told the inspector that if there was something they did not like an alternative would be found. Lunchtime on the day of the inspection was relaxed and unhurried. Residents were able to eat in the lounge or their bedrooms if they wished. One resident chose to have their main meal in the evening and just fruit at lunchtime. Residents stated they could have their breakfast in their bedrooms if they wished. One of the residents spoken with stated she only had ice cream for pudding due to being on a special diet and the food records supported this. This was discussed with the manager and she was to ensure further choices were made available for this resident. Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 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 standard(s) 16 and 18. There was an appropriate complaints procedure that all residents received a copy of. A record must be kept of all complaints made to include the investigation and any outcomes so that it can be determined they have been investigated and resolved appropriately. There were adequate policies and procedures on site for adult protection and physical intervention for staff to follow to ensure the protection of the residents. EVIDENCE: There was an appropriate complaints procedure on site and all residents received a copy of this. The manager stated the home had not had any complaints however it was noted that one, albeit minor, was discussed in a staff meeting. The manager needed to ensure that all complaints were logged and details included of any investigations and outcomes. No complaints had been lodged against the home with the CSCI. There were appropriate adult protection and physical intervention policies on site. No issues in relation to adult protection had arisen at the home. Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 24, 25 and 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 which was suitable for its stated purpose and well maintained. It was comfortable and homely with a good standard of furniture, fittings and décor. Since the last inspection all the corridor, stairs and lounge carpets had been replaced which improved the environment further. 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. There was an ongoing outstanding requirement made by the environmental health in relation to the ventilation in the kitchen. This was being pursued by Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 Page 16 the proprietors but due to the positioning of the kitchen and the size of the commercial extraction units available was proving problematic. The requirement had been raised again by environmental health at a recent visit and must be addressed. 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. 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 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. It was noted that the temperatures of the hot water to the wash hand basins was well in excess of the recommended 43 degrees. All hot water outlets to the wash hand basins needed to be risk assessed and thermostatic mixer valves fitted in order of priority. 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. Since the last inspection more appropriate storage had been found for the wheelchairs but 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 needed to ensure that all the required furniture was made available to residents, for example, two chairs. If residents did not require all the furniture this needed to be documented. 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. The home was found to be clean and odour free. There were infection control procedures on site and protective clothing was available for staff. There was a system for the disposal of clinical waste. The laundry was appropriately located and equipped. Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30. Adequate staffing levels were being maintained to meet the needs of the residents. All staff must receive induction training facilitated by the appropriate people to ensure they are equipped with the necessary skills and knowledge to fulfil their roles. Recruitment procedures must be applied consistently to ensure the protection of the residents. EVIDENCE: There had been little staff turnover since the last inspection and the acting manager was trying to recruit more staff to ensure they could have three staff on duty consistently between four and seven pm. Staffing levels were being maintained to three staff up until five pm and two after this time. These levels appeared to meet the needs of the residents. Without exception the residents spoken with were happy with the staff group stating they were kind and helpful. Two staff files were sampled. One had all the required documentation and evidence of employment checks the other did not have a CRB or POVA first check and there was no reference from the previous employer and no evidence that this had been explored with the employee. It was also strongly recommended that the manager kept records of the interviews undertaken with prospective employees. New care assistants were receiving induction training however this was being facilitated by a care assistant and this is not within their role. Induction Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 Page 18 training must be carried out by senior staff who take responsibility for this and to ensure all new staff are receiving the same information. The induction training for care staff must also be cross-referenced to the guidelines laid down by the Care Skills Sector to ensure all areas are covered. It was noted that a new cook had been employed and there was no documented induction. All staff need an induction into the home that includes, health and safety issues, the philosophy of the home, the rights of the residents and so on. There was a training matrix in the home that detailed when staff were due to undertake mandatory training including, manual handling, food hygiene, fire and first aid. Other planned training included challenging behaviour, record keeping and communication. Thirty three percent of staff were qualified to NVQ level 2 or the equivalent. The manager was aware that the requirement for this is fifty percent. Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36, 37 and 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 home needed a formal quality monitoring system in place based on seeking the views of the residents to ensure there was a system in place for continuous improvement. The health and safety of the staff and residents was well maintained. EVIDENCE: A new manager was in post at the time of the inspection and had been employed at the home since March. She demonstrated a good knowledge of the residents in her care and the running of a care home. The proprietor of the home needed to ensure that an application for the manager’s registration was forwarded to the CSCI. Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 Page 20 All the residents spoken with were happy that the new manager listened to them and would resolve any issues raised. There appeared to be an open and inclusive atmosphere in the home and good relationships were evident within the staff team and communication appeared to be good. There were informal ways of monitoring quality in the home including staff meetings, questionnaires for staff, residents and visitors. However there needed to be a formal quality monitoring system developed in the home based on seeking the views of the residents. It was strongly recommended that resident meetings were developed to discuss such things as menus, activities and any issues arising the home. Where the manager was handling any money on behalf of the service users the records were generally acceptable and receipts were available for expenditure. The manager needed to ensure that where joint receipts were issued for expenditure, for example, for chiropody that they were sufficiently detailed. All the balances checked at the time of the inspection were correct. The manager stated there was a system of staff supervision in the home, the records for this were not inspected, however it did not meet the required level of six supervision sessions per year for care staff. Generally the records required by regulation for the protection of service users were in order and up to date. Those requiring further development included recruitment checks and care plans. Health and safety were well maintained and staff had received training in safe working practices. There was evidence on site of the required checks being made on the fire system, with the exception of the weekly fire alarm checks, where some gaps were noted. There was evidence on site of all equipment having been serviced. The one safety issue raised was the temperature of the hot water to the wash hand basins. 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 good however not all the required notifications had been forwarded to the CSCI. Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 2 2 2 x 2 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 2 3 1 x 2 2 2 2 Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 Page 22 Yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 6(a) Requirement The statement of purpose and service user guide must be updated to reflect the current staffing in the home. 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. The manager must ensure that a copy of the social workers assessment is obtained prior to admission of any residents where applicable. All residents must have care plans that detail all their needs in respect of health and welfare and how these are to be met by care staff. There must be evidence that wherever possible the residents have been consulted about the care plans. All residents must have manual handling risk assessments. (Previous time scale of 01/05/05 not met.) Daily records must be dated to ensure they can be tracked easily by staff. All medication must be acknowledged as received from Timescale for action 01/09/05 2. 2 5(1)(b) 01/09/05 3. 3 14(1)(b) 01/09/05 4. 7 15(1) 14/08/05 5. 7 13(5) 14/08/05 6. 7. 8 9 12(1)(a) 13(2) 01/08/05 08/07/05 Page 23 Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 8. 9. 10. 9 9 9 13(2) 13(2) 13(2) 11. 9 13(2) 12. 12 12(1)(a) 13. 15 16(2)(i) 14. 16 17(2) schedule 4(11) 15. 19 23(5) 16. 17. 20 21 16(2)(c) 13(4)(a) (b)(c) 18. 22 23(2)(l) the pharmacist on the MAR sheets. Copies of all prescriptions must be kept and cross referenced to the medication received There must be a complete audit trail for all medication held in the home. Tablets remaining in containers must correspond with the amounts received and administered. The manager must undertake staff drug audits to ensure the competency of staff in handling medication. Staff must record how residents are spending their days and the activities on offer to evidence their social needs are being met. The registered person must ensure that choices of meals are available for any residents on special diets. 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. Improvements must be made to the ventilation in the kitchen as required by the environemntal health officer. (Previous time scale of 01/06/05 not met.) Any worn armchairs must be replaced. (Previous time scale of 01/06/05 not met) The temperatures of the hot water to all the wash basins must be risk assessed and thermostatic mixer valves fitted in order of priority. Appropriate storage arrangements must be made for the hoist. (Previous time scale of 01/05/05 not met.) 08/07/05 15/07/05 15/07/05 14/08/05 14/08/05 14/08/05 14/08/05 01/09/05 01/09/05 01/09/05 01/09/05 Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 Page 24 19. 24 16(2)(c) 20. 21. 28 29 18(1)(a) 19(1)(a) (b) 22. 29 19(b)(i) 23. 24. 25. 30 30 30 18(1)(a) 18(1)(a) 18(1)(a) 26. 27. 31 33 8(1)(2) 24(1)(a) (b) 28. 35 17(2) schedule 4(9)(a) 29. 36 18(2) The registered person must ensure that all bedroom furnishings required by the National Minimum Standards is available to residents. If residents do not want all the required furniture this must be documented. (Previous time scale of 01/06/05 not met.) 50 of care staff must be qualified to NVQ level 2 or the equivalent. All staff must have either a POVA first or CRB check in place prior to their commencing their employment. (Previous time scale of 01/04/05 not met.) wherever possible one of the references obtained for staff must be from the former employer. (Previous time of 01/04/05 not met.) Induction for new staff must be facilitated by senior staff. Ancillary staff must underatke induction training. Induction training must be cross referenced to the guidelines laid down by the Care Skills Council to ensure all the required araeas are covered. (Previous time scale of 01/04/05 not met.) An application for the regsitration of the manager must be forwarded to the CSCI. 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.) Where joint receipts are issued for expendutire made on behalf of residents these must be adeqautely detailed and signed to ensure they cannot be altered at a later date. All care staff must receive a minimum of six supervison 01/09/05 31/12/05 01/09/05 01/09/05 01/09/05 01/09/05 01/10/05 01/09/05 01/10/05 01/09/05 01/09/05 Page 25 Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 sessions per year. 30. 31. 38 38 23(4)(a) (c)(v) 37 The fire alarm must be tested weekly and records maintained. Notification of any event that affects the well being of the residents must be sent to the CSCI. 08/07/05 08/07/05 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 21 21 29 32 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. It is recommended that records of staff interviews are kept. It is strongly recommended that residents meetings are held. Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Birmingham and Solihull Local 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. Extracts may not be used or reproduced without the express permission of CSCI Bournbrook Manor E54_S17006_BournbrookManor_V228508_070705 - Stage 4.doc Version 1.30 Page 27 - 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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