Inspection on 14/06/05 for Bournville Grange

This inspection was carried out on 14th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Bournville Grange 26/11/08

Bournville Grange 30/01/07

Bournville Grange 18/11/05

Bournville Grange 10/02/05

Bournville Grange 28/07/04

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 Bournville Grange 168 Oak Tree Lane Bournville Birmingham B30 1TX Lead Inspector Brenda O Neill Announced 14 June 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. Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bournville Grange Address 168 Oak Tree Lane Bournville Birmingham B30 1TX 0121 445 5896 0121 472 4552 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) Adam Barwell Claire Brown Care Home 27 Category(ies) of Care Home 27 registration, with number of places Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The category of registration is OP (older people, over 65) and the type of home is care home only 2. The number of residents shall not exceed 27. 3. Staffing levels are maintained at 3 care assistants plus a senior throughout waking day. Two waking night care assistants with one person on call. 4. The former office is refurbished to form an assisted shower and wc for resident use, completed by December 2003. 5. The second rear lounge area is part-partitioned off to extend and improve the wc and make it accessible for people needing support. 6. In conjunction with this a corridor is created to the fire exit and the boiler is protected. 7. By 1st October 2003 a proposal is submitted for a permanent staff room on the second floor to be finalised and resovled within 12 months of registration. 8. Bedroom 16 is improved by reducing the en-suite and repositioning the door. 9. The WC off the laundry is designated for use by kitchen staff. 10. The ponds located in the garden are made safe and secure in order to prevent accidents. 11. That the patio area is made safe from tripping hazards, the severe drop in gradient, the path is made safe and handrails installed. 12. The access and egress from the front of the Home to the rear is made safe and secure. 13. Mrs Brown must provide evidence of completion of a management and care qualification at NVQ level 4 or equivalent by April 2005. 14. Mrs Brown to access up to date training re: vulnerable adults and local procedures for reporting alleges of abuse.. Date of last inspection 10/02/05 Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 5 Brief Description of the Service: Bournville Grange is a large detached property situated in the conservation area of Bournville. The home is within walking distance of local churches, parks and Bournville Village Green, which has a variety of local shops and a post office. Public transport is also within a short distance. The home offers accommodation to 27 elderly people over three floors. All but one of the bedrooms are singles and most have en-suite facilities. residents have a choice of 3 lounges and there is one dining room. All are very comfortable and furnished in a homely style. There are three assisted bath/shower rooms and adequate numbers of toilets throughout the home. Aids and adaptations include a ramped entrance and shaft lift, giving easy access to the first and second floors for those who experience difficulties with mobility. The ground floor of the home also houses the main kitchen, laundry and office space. There is parking space at the front of the home and there are extensive, mature and well maintained gardens to the rear. Many of the rooms have a good view of the gardens. There is a patio with an ornamental pond and seating for residents. Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection and the first of the statutory inspections for the home for 2005/2006. The inspection was carried out over one day by two inspectors. During the visit a tour of the premises was carried out, three resident files and three staff files were inspected as well as numerous policies and procedures, other care records and health and safety records. The inspectors spoke with the proprietor, manager, deputy and other staff on duty at the time and eight of the residents. What the service does well: There was a very relaxed, friendly atmosphere in the home with evident good relationships between staff and residents. Without exception residents spoken with were very happy with the staff group making comments such as: ‘They can’t do enough for you’ ‘ They look after us well’ ‘ I could talk to anyone about anything’ ‘ The comfort and care are good.’ The assessments and care plans in the home were good and contained a lot of detail about how the residents wanted to be cared for and what they could do for themselves. It was obvious that the staff knew the residents well and their likes and dislikes. The meals were good and there were choices available at all meal times. Several of the residents commented how nice it was to be able to have a cooked breakfast every day if they wished. There were no rigid rules or routines in the home and the residents could spend their time as they wished. There were some organised activities available in the home and a variety of parties and social gatherings had taken place. The health care needs of the residents were met and there was a good system in place to ensure they received their medication at the right times. The staffing levels at the home were good ensuring there were enough staff on duty to look after the residents. The home was well managed and the manager was careful when employing staff to ensure all the right checks were carried out before employing anyone. Health and safety of staff and residents were very high priority and extremely well managed. Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 7 The home has been extensively refurbished since the present proprietor took over and provided residents with a very good standard of accommodation that was well maintained and safe. 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. Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5. The home’s statement of purpose and service user guide were good providing residents and prospective residents or their representatives with details of the services the home provided enabling an informed decision about admission to be made. The assessment procedures in the home were good ensuring the needs of the residents were known and could be met by the staff. EVIDENCE: Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 10 There was a statement of purpose and service user guide for the home both had been amended since the last inspection and included all the relevant information. The service users guide was issued to all prospective residents or their representatives. The resident’s files sampled evidenced that where applicable social workers had undertaken assessments and drawn up the initial care plans for the residents. In addition the home’s management team were carrying out their own assessments on the pre-admission visits to the home to ensure that prospective residents met the criteria for the home and that the home could meet their needs. Once admitted to the home further assessments were undertaken these informed the first care plan that was drawn up. All residents were being issued with a statement of terms and conditions of residence at the point of admission to the home. The detail in relation to complaints included in this needed to be amended as it conflicted with the complaints procedure for the home and did not make it clear that complaints could be referred to the CSCI at any point. All the residents spoken with were happy that their needs were being met and all appeared content. The practices observed throughout the inspection evidenced that staff were able to meet the needs of the residents, for example, interactions with residents with dementia, appropriate activities and appropriate assistance with personal care. There was also evidence on daily records of personal care needs being met and of the general medical needs of residents being met including, chiropody, optician and doctors visits. There were aids and adaptations throughout the home to assist those residents with mobility difficulties and to enable staff to assist where necessary. Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, and 10. The care planning system in the home was good ensuring staff knew the individual needs of the residents and how they were to be met. There were comprehensive risk assessments for residents that included strategies for minimising any risks. Staff needed to ensure that all care plans and risk assessments were updated to reflect the current needs of the residents. Health care needs were being identified and followed up and the systems for administration of medication were good ensuring resident’s medication needs were being met. EVIDENCE: Three residents files were sampled and generally the care plans and risk assessments were very detailed. All files had completed nocturnal needs assessments which gave very detailed information in relation to the service users’ needs at night and how staff were to meet these needs. The care plans detailed resident’s needs in several areas of their lives including, personal hygiene, mobility, social activities and communication. There was good detail included of what the residents were able to do for themselves and where they needed assistance. One of the care plans seen needed updating in relation to the progress made on obtaining a hearing aid for the individual and the ongoing treatment being received. Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 12 There were manual handling and personal risk assessments on all the files sampled and the majority were well documented and explained how staff were to minimise risks. It was noted that one resident had had several falls however there was no risk assessment in relation to this. Also the manual handling risk assessments needed to include the size of the sling to be used where a hoist was needed. The residents spoken with were happy that their health care needs were being met. One commented about the frequent visits from the district nurses to treat his pressure areas that had been ongoing since before admission to the home but which were now improving. There was evidence on the resident’s files of health care needs being met, for example, doctors and optician’s visits and chiropody treatment. Tissue viability and nutritional screenings had been undertaken for all residents and weights were being monitored on a regular basis. Staff needed to be consistent when make recordings about the health and welfare of the residents as there were some gaps. This was discussed with the manager who had already identified the problem and was addressing it. Very good systems had been installed in the home for the management of medication. All medication was being acknowledged when received into the home, administered and disposed of. Only senior staff were administering medication. One very minor recoding error was noted but this would have had no impact on the health and safety of the resident. There were no issues raised in relation to privacy and dignity during the course of the inspection. Staff used appropriate terms of address and spoke respectfully to residents. Medical consultations took place in the resident’s own rooms. Resident’s could receive visitors in their rooms or one of the quieter areas of the home if they wanted privacy. All bedrooms had been fitted with appropriate locks and Keys were available for residents. There was only one double room in the home and this had had a privacy curtain fitted since the last inspection. Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 and 15. There were no rigid rules or routines in the home and activities were available to offer stimulation to residents. Documentation needed to detail the activities residents were taking part in to evidence their social needs were being met. The meals in the home were good with choices available for residents. EVIDENCE: There did not appear to be any rigid rules or routines in the home and residents confirmed they could spend their time as they chose. Residents were seen to be wandering around freely, spending time in the lounges watching television, reading newspapers taking part in activities and spending time in their bedrooms. There were some activities on offer at the home including reminiscence, progressive mobility and board games. Staff did take residents out for a walk to the local park and there were occasional visiting entertainers. A variety of themed events did take place in the home, for example, a Hawaiian tea party was planned and there had been parties for Valentine day and VE day. Residents also visited the other homes of the proprietor for social events. Resident’s likes, dislikes and preferences were detailed in their care plans. Staff needed to ensure they documented the activities residents were taking part in or declining to evidence they were meeting their social needs. Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 14 There did not appear to be any restrictions on visitors to the home in reasonable hours. Visitors were seen to come and go throughout the course of the inspection and seemed to be made very welcome and very friendly relationships with staff were evident. The inspectors joined the residents for lunch on the day of the inspection and the meal was well cooked and presented. Staff were available to assist throughout the meal if they were needed. All the residents spoken with were happy with the catering arrangements at the home and confirmed they had choices at all meal times. A new cook had been appointed and residents seemed happy with her cooking and stated she did go around the home and enquire if they liked the food. Residents were able to have a cooked breakfast every day if they wished. Although there was a dining room at the home some residents chose to eat in the lounges and could also have their meals in their bedrooms if they wished. The dining room was a very pleasant room, well furnished and decorated. Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 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 standard(s) 16 and 18. Residents were issued with a copy of the complaints procedure and seemed confident that any issues raised would be addressed. Adult protection issues that had been raised at the home had been appropriately addressed ensuring residents were protected from abuse. EVIDENCE: The manager stated the home had not received any complaints and none had been lodged with the CSCI. There was a complaints procedure and all residents received a copy of this in the service user guide and these were seen in resident’s bedrooms. Residents spoken with stated they would have no hesitation in approaching the manager with any concerns and were confident they would be resolved. The majority of staff had received training in adult protection and the manager had demonstrated her understanding of the multi agency guidelines for adult protection by acting appropriately when issues had been raised at the home. All the relevant procedures for adult protection and physical intervention were available on site. Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 24, 25 and 26. The standard of the environment within this home was very good providing residents with an attractive, safe, comfortable and homely place to live. EVIDENCE: The home has been extensively refurbished since the present proprietor took over and provided residents with a very good standard of accommodation that was well maintained and safe. All the requirements made at the last inspection have been met including, a ramped exit into the grounds, the fitting of bedroom locks has been completed and the hazardous area of the grounds fenced off. There had been a very recent made to the home by the fire officer and his requirements were being followed up. There were ample communal areas in the home with three lounges and a dining room. Since the last inspection one lounge had been redecorated and all lounges had had new armchairs, which varied in style and colours, and occasional furniture. Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 17 Throughout the home were two fully assisted shower rooms and one assisted bathroom. The majority of the bedrooms had full en-suite facilities including showers, others toilets and wash hand basins. There were also additional toilets on the ground and first floors. It was noted that one of the shower chairs in the shower rooms and one of the shower seat fittings in an en-suite were badly rusted and needed replacing. Bedrooms varied in size, were well furnished and equipped and had all had had new armchairs since the last inspection. The fitting of appropriate locks to the bedrooms doors had been completed and keys were available for the residents. All the bedrooms seen were personalised to the occupant’s choosing. There were a variety of aids and adaptations throughout the home including ramped entrances/exits, grab and handrails, shaft lift and emergency call system throughout the home. The heating and lighting throughout the home was safe, domestic in character and met with the needs of the residents. The home was clean, hygienic with appropriate procedures in place for the disposal of clinical waste and protective clothing available for staff as necessary. The laundry was appropriately equipped with a sluice washing machine and tumble drier. Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 by a trained staff group that could meet the needs of the residents. Induction training needed to be completed in six weeks after employment to ensure staff were equipped with the necessary skills and knowledge in a timely manner. There were robust recruitment and selection procedures at the home ensuring the protection of service users. EVIDENCE: The rotas sampled evidenced that the required staffing levels were being maintained and that the home was meeting the condition of registration in relation to staffing at the time of the inspection. Ancillary staff were employed for cooking, cleaning, and maintenance. There were some very positive interactions observed between staff and residents. Residents spoken with were very happy with their relationships with the staff and stated staff were very kind and helpful. The recruitment files for three of the newest employees were sampled and all the required information was available which evidenced a robust selection and recruitment procedure. There was a structured induction procedure for new staff at the home which covered all the required topics however this was not always completed within the required time scale of six weeks. The majority of staff had undertaken all Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 19 the required mandatory training including, manual handling, fire procedures, health and safety and food hygiene. Other training topics covered included adult protection and dementia care. Twenty three percent of staff were trained to either NVQ level 2 or 3, this needed to be increased to fifty percent but the manager was aware of this and several other staff were undertaking the qualification. Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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. The health and safety of the residents and staff was very well managed. The home needed to formalise their systems for monitoring the quality in the home to ensure the quality of care being provided is in keeping with the aims and objectives of the home. EVIDENCE: The manager had many years experience of working with older people and had been in post since March 2003. She had completed NVQ level 3 and was undertaking her Registered Managers Award. She was aware of the requirement for this to be completed by 2005. She gave evidence during discussions of her knowledge of the residents in her care and the running of a care home. The continued to improve in all aspects under her management including the care offered, administration and staffing. Throughout discussions it was evident she was eager to meet any requirements made. Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 21 Staff and service users expressed the view that they would have no hesitation in approaching the manager or the proprietor with any issues that arose and were confident they would be addressed. Resident and staff meetings were being held giving staff and residents the opportunity to air their views and discuss a variety of issues. There were systems in place for monitoring the quality of the service offered including questionnaires for residents and relatives, health and safety audits by outside agencies and residents meetings. However both the manager and the proprietor were aware of the requirement to have a formal quality assurance system in the home. The manager was only holding money in safe keeping for one resident at her request and a record of this was being kept. For those residents who were unable to handle their own finances the proprietor would purchase any items the service users required and then invoiced the appropriate person. Staff were receiving supervision from either the manager or deputy manager however the required level of six sessions per year was not being achieved. There was an abundance of policies and procedures on site which were regularly reviewed. All the records sampled during the course of the inspection were well ordered and up to date. The responsible individual for the home needed to ensure that there were reports of their monthly visits to the home were done consistently and available for inspection. Health and safety at the home were very well managed. Staff had received training in safe working practices, there were infection control procedures on site and appropriate systems in place for the disposal of clinical waste. There was evidence on site of the regular servicing and maintenance of all equipment and all the in-house checks on the fire system were up to date. There were numerous risk assessments in place for the premises and an outside agency had completed the fire risk assessment. The owner of the home had recently commissioned an outside agency to carry out a health and safety audit on the home, which was very extensive, and the manager had just received the report. Accident and incident recording and reporting were appropriate. Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 4 3 2 3 x 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 2 x 3 2 2 4 Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 23 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 2 Regulation 5(1)(b) Requirement The statement of terms and conditions must be amended to ensure the section on complaints does not conflict with the homes compalints procedure. Care plans must reflect the current needs of the residents. If manual handling risk assessments state a hoist is to be used the size of the sling must be detailed. There must be documented risk assessments for all identiifed risks for residents. Staff must be consistent when recording about the residents health and welfare and ensure this is done at least daily. Staff must record the activities residents take part in or decline to evidence their social needs are being met. The rusting shower chair in the shower room and fittings in the en-suite bathroom must be replaced. A minimum of 50 of care staff must be qaulified to NVQ level 2 by 2005. Induction training for staff must be completed within six weeks of Timescale for action 01/08/05 2. 3. 7 7 15(1) 13(5) 14/07/05 14/07/05 4. 5. 7 8 13(4)(a) (b)(c) 12(1)(a) 14/07/05 14/07/05 6. 12 12(1)(a) 14/07/05 7. 21 23(2)(c) 01/08/05 8. 9. 28 30 18(1)(a) 18(1)(a) 31/12/05 14/07/05 Page 24 Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 10. 31 9(2)(b)(i) 11. 33 24(1)(a) (b) 12. 13. 36 37 18(2) 26 them commencing their employment. The manager must be qualified to NVQ level 4 in management and care or the equivalent by 2005. (Previous time scale of April 2005 not met.) The home must have effective quality assurance and quality monitoring systems in place, based on seeking the views of the residents. (Previous time scale of 01/04/05 not met.) The manager must ensure that staff receive a minimum of six supervision sessions per year. The reports of the visits to the home by the responsible individual must be done on a monthly basis and available for inspection. 31/12/05 01/09/05 01/08/05 01/07/05 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. Refer to Standard Good Practice Recommendations Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 25 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 Bournville Grange e54_S44748_Bournville_V224345_140605 - Stage 4.doc Version 1.30 Page 26 - 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!