Inspection on 25/07/06 for Bournedale House

This inspection was carried out on 25th July 2006.

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

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

Other inspections for this house

Bournedale House 27/05/09

Bournedale House 03/06/08

Bournedale House 27/07/07

Bournedale House 22/03/06

Bournedale House 28/11/05

Bournedale House 21/03/05

Bournedale House 23/09/04

Bournedale House 27/02/04

Bournedale House 13/10/03

Similar services:

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 Bournedale House 441 Hagley Road Edgbaston Birmingham West Midlands B17 8BL Lead Inspector Susan Scully Unannounced Inspection 25th July 2006 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 Bournedale House DS0000016740.V305165.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. Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bournedale House Address 441 Hagley Road Edgbaston Birmingham West Midlands B17 8BL 0121 420 4580 0121 420 4580 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 David Pangbourne Leah Robertson Care Home 11 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (11) of places Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That Ms Leah Robertson provides evidence of completion of a management qualification at NVQ level 4 or equivalent at the earliest opportunity or before April 2005. The category of registration is OP (older people, over 65), DE(E) (Dementia over 65) and the type of home is care home only. The resident numbers shall remain at 11. Date of last inspection 22nd March 2006 Brief Description of the Service: Bournedale House is located approximately 3 miles from Birmingham city centre, and within walking distance of Bearwood shopping centre. Facilities such as churches, public houses, restaurants, library and parks are close to the home. Bournedale House is a large Victorian property providing accommodation to 11 older adults. Care is provided on the ground and first floors, a chair lift provides access to the first floor facilities. On the ground floor there is a main lounge, dining area and kitchen, with toilet and shower facilities within easy reach. The lounge is to the rear of the property, is spacious and provides nice views of the rear garden. There is a shared double room to the ground front of the property that provides accommodation for two service users who require ground floor facilities. This room has privacy screens. The first floor facilities consist of spacious single bedrooms with ample storage, some with original Victorian fireplaces. The bathroom has a bath hoist to assist persons into the bath; there is also a shower. There are grab rails located in toilets and around the home to aid service users. There has recently been an assessment of the environment and service users needs. This has led to the provision of aids and equipment suited to the needs of people who require assistance. Raised chairs, pressure cushions for chairs, and handrails at the top of the stairs have been provided. Individual service users have been provided with zimmer frames to enhance their mobility and independence. Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection took place over a one-day period. Records pertaining to residents were sampled and included: care plans, risk assessments, daily notes, fire Safety records, accident records, complaints, compliments, and staff rotas. Information was also obtained before the fieldwork and included: A Pre-questionnaire, comment cards and information that had been received at the commission such as history of regulatory activities. Records pertaining to Health and Safety were also sampled, these include Gas Safety checks, electrical appliances testing, water temperatures, infection control, safe storage of Hazardous Substances, food hygiene and manual handling assessments. The inspector would like to thank the service users and staff for their contribution made during the visit. What the service does well: What has improved since the last inspection? A new manager has been appointed, who demonstrated her knowledge and experience of the service users being accommodated. Some decoration had been completed to the environment. The provider informed the inspector he would be working closely with the acting manager to improve the environment further and target the needs of service users to establish how the environment can be improved. Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 6 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. Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in the outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The continuing support required after admission is not recorded to ensure staff have relevant information about the person to provide the basic principles of care. EVIDENCE: Since the last inspection, four service users have been admitted. The assessment completed by the social worker was satisfactory at the initial stage. When sampling records pertaining to the service users information had not been transferred into a plan of care. The information recorded did not include factors that may affect the type of care required, such as medical factors and prognosis, or any relevant social circumstances. Four-service users have a degree of dementia and care plan must be completed to include environmental issues, risk assessment and identify any Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 9 special requirements needed. The acting manager has been in post since July 12 2006 and is aware of the need to ensure all relevant information is recorded on individual plans of care. The information must demonstrate how the initial assessment will be incorporated into a detailed plan of care. The manager said she had not had the opportunity to transfer the information from the initial assessment in to a comprehensive plan of care as additional information was required to ensure all need areas were met. Staff were working from the social workers assessment in the interim period. Intermediate care is not provided. Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in the outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans have not been reviewed to incorporate aliments and the diagnosis of dementia to ensure specialist needs are met. Healthcare records are not recorded in sufficient detail to provided relevant information to the reader or to ensure needs are met. Information is not recorded to reflect the care being provided. Medication records are not adequate to ensure a comprehensive audit to establish if the service user have received the correct medication at the correct time. Privacy, respect, dignity is maintained. EVIDENCE: Information in care plans and health care records did not demonstrate how personal and healthcare needs were being met. Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 11 Plans of care had not been reviewed. Information contained in one care plan indicated the service user required monitoring with weight; there were no records of weight being recorded. One service user remained in bed most of the time, there was no information to show how staff interacted with this service user or time set aside in the care plan for staff to ensure the service user had interaction on a regular basis. The district nurse attended three times a week in order to maintain pressure care. The care plan did not show how staff supported the service user on days when the district nurses were not in attendance. Plans of care sampled did not identify what care was to be provided or how to provide the basic principle of care. The acting manager said they were using a new system that did not give adequate information to the reader. She was in the process of discussing the format and contents with the provider to change the way relevant information was recorded and had already started the process. The acting manager said she would be reviewing all care plans. The current care plans do not take into account the degree of the service user dementia. Health care records did not show the degree of support required with certain health related issues. For example one service user had a broken arm, there was no information to show how this service user was supported in personal care, or maintaining every daily living skills. When speaking with the service user he did not know when the plaster would be coming off but was looking forward to it, the service user said, “I am quite happy and staff have helped me a lot over the weeks with washing and dressing’’. The acting manager said the plaster was due to be taken off sometime in the week. There was no risk assessment or specific instructions to staff to make allowance for the inability to use the arm as normal. No instruction were seen that indicated the service user required assistance with personal care in additional to what was normally required. One service user had an hearing impairment the care plan did not give information of how to communicate with this service users, such as speaking face to face, or ensuring the service user can see the person who is speaking. There was no risk assessment for the provision of the fire alarm. One service user has a combination of different aliment, such as being hard of hearing; poor eyesight and dementia. Information was recorded but did not address each aliment and show what support was required. All risk assessments required review to show how the risks are managed. When the inspector was shown around the home, in one service users bedroom cream, which the staff did not know what was for, was found. The acting manager said she had no idea what the cream was used for and sought Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 12 confirmation from colleagues. The member of staff said it was something the relatives had brought in over the weekend. The service user confirmed she did not know what the cream was for. The acting manager must discuss with staff the importance of recording homely remedies when relative bring un- prescribed medication into the home. Clear instruction must be recorded, such as what the homely remedies are for and how to administer the medication. The acting manager said the home do not give homely remedies they just call the doctor. This is a cause for concern; if a service user had, a headache then until the doctor was called the service user would be in pain, which is not acceptable. It is recommended the acting manager consult with the GPs of service user with a view to storing some homely remedies. Medication records showed medication is not carried forward on Medication Administration Records (MAR charts) resulting in ether there being too much medication or too little medication. An audit could not be completed. Training records pertaining to staff that have received training in administration of medication were not seen and must be forwarded to the Commission within seven days of receiving this report. No member of staff must administer medication unless training has been provided. Interaction between staff and service users was positive. Observations made during visit showed staff interacted with service users in a positive and courteous manner-showing respect and maintaining dignity with personal care. The staff team have been at the home for a number of years, which provides stability for service users. Staff spoken with demonstrated their knowledge about service users personal care, history and how they like to be cared for. Service users said staff were really good to them. One service user said, “The staff are really good they know what I like. They are always kind and supportive. They are a lovely bunch of girls and it is really nice here’’. One service user said, “I have been here for years, I really like it the staff are really nice, they treat you with respect and are always willing help’’. Observation made during the visit showed staff interacted well with service user in a relaxed and friendly environment. The recording of information significantly let the home down and does not provide consistency. The acting manager said once she has implemented the new format and recording methods, information would portray the actual care being provided. Service users are happy with the care they receive and are well presented in appearance. Daily records show regular visit to the hairdresser, chiropodist, GPs, optician, dentists and service users are supported to attend hospital appointment. Bournedale House DS0000016740.V305165.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, 15 Quality in the outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Regular activities take place and are recorded in daily records. Service users daily routine is flexible this enables service user to participate at their own pace. Regular contact with friends and family is recorded. Breakfast and lunchtime meals are varied and meet service users needs. The teatime meals are not adequate in size and offer no choice, which may result in service user being hungry and placed at nutritional risk. EVIDENCE: When speaking with service users one said, “it is nice here because if you don’t want to do any activities then you don’t have too. But most days there is something going on, even if it is staff taking about the past which is nice, they have sing-along and some social gatherings, they always invite your family’’. “You can do what you want really’’. Any activity the service user participates in is recorded with a summary of how well the activity went or if there was little participation. The acting manager said it was a case of establishing what activities the service users want. It is Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 14 recommended the acting manager consults with relatives regarding previous activities each service user participated in before admission and incorporate this into the activity programme particular for those who have been diagnosed with dementia. Service users maintain regular contact with friends and family and there is no restriction on visiting times. When speaking to relatives, one said the staff were always friendly and had no concerns about the care provided. Comment cards received before the inspection gave a positive view of the care provided. Meal times provide social interaction; staff said service users get on well. Menus are varied and show a choice of meal for lunch. Teatime is not varied and consists of mainly sandwiches with no choice of a hot meal. On the day of the visit, the teatime meal consisted of cakes, sandwiches and crisps. The inspector was told and later confirmed by observation the sandwiches were prepared in the morning then placed in the fridge for tea at 4pm. The sandwiches had been prepared at 11am, and when the inspector sampled the sandwiches, they were hard and cold. The number of sandwiches planned would only give the 10 service users two quarter sandwiched each with a small cake. This is not acceptable and the inspector requested further provision for the teatime meal to be provided. The provider and acting manager were present when the inspector sampled the sandwiches. Both agreed the provision of the teatime meal was not adequate and promptly made alternative arrangement. The acting manager said two care staff are on duty each evening and one member of staff will be taken of the floor at teatime, leaving one member of staff to support 10 service users. Alternative arrangement must be made to ensure staffing levels do not infringe on service user personal support at peak times. The cook has been employed at the home for a least 10 years and service user spoke highly of the meals she provides. Training in food hygiene had not been completed in the 10 years the cook had been employed. The cook must complete an intermediate course in food hygiene. Bournedale House DS0000016740.V305165.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 the outcome area is adequate this judgement has been made using available evidence including a visit to this service. There are systems in place to enable any concerns or complaints to be identified and resolved. There is minimal information available to judge how effectively this is managed. However, concerns have been listened to and acted upon to the satisfaction of the individual. Training records were not in date and do not fully reflect that all staff has received training in adult protection. EVIDENCE: A complaints logbook has been implemented since the last inspection. This is to record all complaints made including details of the investigation and any action taken. There were no entries made in the logbook at this inspection. From discussions with service users, it is evident that they would require a great deal of support to utilise this procedure, or an advocate to act on their behalf. The provider must ensure there are plans to implement procedure to address the communication difficulties identified in service user care plans. Training records were not available to show if all staff had received training in adult protection. Staff spoken to gave a clear indication what they would do if they suspect any form of abuse. The acting manager said a training matrix Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 16 showed some staff had received training, but as she had only been in post for two weeks she was still at the induction stage and was still trying to establish what work was required regarding her management responsibilities. Accident records showed the appropriate action was taken when an accident occurred. No follow-up information such as monitoring when service users had an accident was recorded in daily records. All incidents are reported to the Commission on the relevant documentation. Bournedale House DS0000016740.V305165.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in the outcome area is poor this judgement has been made using available evidence including a visit to this service. The environment is comfortable and clean. Area identified in the body of the report such as bed linen and cleaning in certain areas must be monitored. All requirements from the environmental health and fire officer visit must be completed. Further improvements are required pertaining to meeting the needs of service users with dementia. EVIDENCE: The environment was clean and fresh. Certain improvements in the environment would enhance the quality of life for service users who have dementia. Such as signs on door, wall, showing where service user are at that point. Giving direction to toilets and bathrooms. It is recommended the provider and acting manager seek professional assistance of how the environment can be improved to ensure all the needs of service user are met. Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 18 Service users said they felt the home was comfortable and were happy with their rooms, which were personal to the individual. Bedrooms were pleasant and clean. Bed linen was seen to have stains on both the bottom sheets and top sheets in one service user room. The acting manager said there was a rota when bed line was change. However, provision must be put in place to ensure that when sheets are dirty they are changed regardless if it is the day for changing that particular bed. The home uses a stair lift up to the first floor. The servicing certificate was not seen during the visit and a copy must be forwarded to the Commission. The dining area is small, but comfortable for service user to eat their meals. The communal bathroom is fitted with aids and equipment to assist those with difficulties. The mat in the bathroom was torn which could cause a trip hazard. Corridors and communal areas are fitted with grab rails to assist service users. A call system is installed which enables service users to alert staff when they need help. Chairs have been fitted with leg raisers to ensure they are at the right height for individuals to use safely. The lighting is domestic and creates a soft homely atmosphere. The radiator in the corridor is not covered and places service users at risk from burns. The kitchen is domestic in style and in general clean and well maintained. The acting manager must ensure there are detailed procedures in place for cleaning and the disposal of domestic waste. On the day of the visit, the microwave required cleaning and there was a bag of rubbish hanging on the door handle in the kitchen. The environment is comfortable and well maintained. All areas of the home were found to be clean, and odour free. The provider has not address areas identified by the Environmental Health and include: • Fly screen to windows. • Damage to the floor in the kitchen • Probing of food to assert the correct serving temperature • Wedging open of doors leading to the kitchen and laundry. • Providing a suitable sanitizer for cleaning. • COSHH product being stored securely. During the visit, doors were wedged open that lead directly on to the Laundry area. COSHH products were stored under the sink with no lock. There was no fly screen to windows. The extractor fan over the cooker required cleaning. The cook did not probe food to ensure the correct serving temperature was reached. Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 19 The provider must ensure all requirements made by the Environmental Health are completed. Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in the outcome area is adequate this judgement has been made using available evidence including a visit to this service. The skill mix of staff is not recorded in training records to demonstrate service users are protected and staff skills meet service users needs. Training records do not demonstrate all staff is suitable qualified. Residents are not protected by the homes recruitment practise and this places service users at considerable risk. EVIDENCE: Training records were not up to date. For example, the training matrix shown to the inspector indicated the cook had completed training in food hygiene. When speaking with the cook it was identified this has been completed 10 years ago. There is no information on the training matrix to show if staff have received training in adult protection. There are no dates to show when the training was completed or when an up date was required. Training requirements must be identified for all staff to ensure staff are suitably qualified to the work they are to perform. Training must demonstrate service users are cared for by suitably qualified and competent staff at all times. Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 21 Staff must complete training in dementia, this is outstanding from the last inspection. Records did not confirm all staff had received training in all mandatory areas. Recently recruited member of staff did not have all the necessary check made as required in Schedule 2 of the NMS and to ensure the welfare of service users. The provider had recruited four members of staff recently and openly admitted he had not followed the homes recruitment procedure. Staff had been employed without POVA and criminal records checks being completed. The provider said the POVA checks had now come through. This is not acceptable and places service users at considerable risk. This practise must cease immediately. Under no circumstances must staff be recruited without all the relevant checks being completed. Records pertaining to induction were incomplete. Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 38 Quality in the outcome area is poor this judgement has been made using available evidence including a visit to this service. The acting manager demonstrated her experience and knowledge and commitment to ensure service users are protected and their health and welfare are maintained. The acting manager and provider are working together to ensure the home is run in the best interest of service users. The recording of information significantly let the home down and did not demonstrate how service users are protected. Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 23 EVIDENCE: The acting manager has been in post for two week before the inspection. When speaking with the manager she clearly demonstrated her experience and knowledge of the service users needs that are currently accommodated. The acting manager said she had a lot to do to bring the home up to standard and at present was observing areas were improvement were required. The acing manager recognised the need for the environment to be more adapted for service users with dementia. An application will be made to the Commission shortly for the acting manager to become the registered manager. Service users spoken to said in the short time the manager had been there she was pleasant and approachable. Staff said things had improved in the short time and felt the changes were needed for a number of years. The last manger was autocratic and did not let staff participate in the care plans or the running of the home. The deputy manager had little knowledge of where things were due to not being able to assist in the management of the home. The provider and acting manager are discussing issues of concern. The provider said he would give the acting manger his full support. At present the provider and acting manager are discussing ways of improving this service to ensure, the home is run in the best interest of the service users. Health and safety records pertaining to the servicing of equipment had been completed. The stair lift-servicing certificate was not seen or the landlords gas safety certificate. Both these documents must be forwarded to the commission. Weekly fire alarm testing had not been completed; the last recorded date was 23 June 2006. COSHH items were not stored securely. Infection control is not maintained in line with Policies and Procedures. The laundry is directly off the kitchen; doors to the laundry were wedged open. No risk assessments are in place for the cleaning of commodes. The fire risk assessment is not dated and did not take into account the finding of the recent fire safety officer visit. A number of requirements are outstanding from the fire officers visit and include the wedging open of the laundry door, and a number of fire resisting doors not closing into the rebate. The provider must provide the Commission with an action plan to address these issues within seven days of the recent of this report. Training records did not show how service users were protected. A quality assurance and quality monitoring system must be introduced. A copy of the landlords gas safety certificate and stair lift service report has been received since the inspection. Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X 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 3 13 3 14 X 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 1 Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 15(1) Requirement An individual plan of care must be produced once the initial assessment has been completed. This must be in full consultation with the service user or reprehensive. A service user plan of care must be generated from a comprehensive assessment (see Standard 3) must be drawn up with each service user and provides the basis for the care to be delivered. Care plan must be kept under review. The registered person must promote and maintain service users’ health and ensure access to health care services to meet assessed needs. All care plans must show what support is given to service users when areas of needs change. The registered person must ensure that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take DS0000016740.V305165.R01.S.doc Timescale for action 01/09/06 2 OP7 15(1) 15(1)(b) 01/09/06 3 OP8 13(b) 01/09/06 4 OP9 13(2) 01/09/06 Bournedale House Version 5.2 Page 26 5 OP15 16(2)(i) 6 OP18 13(6) responsibility for their own medication if they wish, within a risk management framework. All homely remedies must be recorded. The registered person must ensure that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. The Responsible Person must ensure that all staff receives training in adult protection procedures. Outstanding from the last inspection. Previous timescale 01 June 2006. The Responsible Person must ensure that those corrective measures highlighted in the fire officer’s report, are addressed. Outstanding from the last inspection. Previous timescale 01 June 2006. All outstanding requirements from the environmental health report must be completed. All COSHH items must be locked in an appropriate facility. All bed linen must be changed as needed. Staffing levels must be maintained at peak time to ensure no infringement on service user welfare and support is compromised. Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff DS0000016740.V305165.R01.S.doc 01/09/06 01/09/06 7 OP19 23(4)(a) (d) 01/09/06 8 9 10 11 OP19 OP19 OP26 OP27 16(2)(j) 13(4)(c) 16(2)(c) (e) 18(1)(a) 01/09/06 01/09/06 01/09/06 01/09/06 12 OP27 18(1)(a) (i) 01/09/06 Bournedale House Version 5.2 Page 27 13 OP28 13(4)(c) 14 OP29 13(4)(c) 19(1)(a) (b) S2(1-7) 15 OP30 19(5)(b) /hours in respect of service user needs based on guidance recommended by Department of Health. All staff must receive an induction when commencing employment and a record of this maintained. All the relevant checks must be completed before the commencement of employment. Two satisfactory references, POVA check and criminal records check. Application from with an explanation of any gaps in employment. Medical clearance, and proof of ID, confirmation of any qualification relevant to the work they are to perform. The Registered Manager must confirm that the planned mandatory training in first aid, health and safety and fire safety, has been undertaken with all staff. 01/09/06 01/09/06 01/09/06 16 OP31 17 OP33 Outstanding from the last inspection. Previous timescale 01 July 2006. 8(1) An application must be completed and sent to the commission for the acting manager to become the registered manager. 24(1)(a,b) An Effective quality assurance and quality monitoring systems must be produced based on seeking the views of service users and report on the success in meeting the aims, objectives and the statement of purpose of the home. 01/11/06 01/11/06 Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bournedale House DS0000016740.V305165.R01.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!