CARE HOMES FOR OLDER PEOPLE
Bournville Grange 168 Oak Tree Lane Bournville Birmingham B30 1TX Lead Inspector
Jill Brown Key Unannounced Inspection 30th January 2007 09:15 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 Bournville Grange DS0000044748.V329760.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. Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Bournville Grange Address 168 Oak Tree Lane Bournville Birmingham B30 1TX 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) 0121 472 2213 0121 472 4561 bournvillegrang@aol.com Bournville Grange Limited Ms Claire Brown Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The category of registration is OP (older people, over 65) and the type of home is care home only. The number of residents shall not exceed 27 Minimum staffing levels for 27 residents are maintained at three care assistants plus a senior carer throughout the waking day. Two waking night care assistants with a nominated person on call. The care manager hours are supernummery to care hours. Ancillary staff must be provided in addition to care staff. Mrs Brown must provide evidence of successful completion of a management and care qualification at NVQ level 4 or equivalent by April 2006. To accommodate one named service user within existing numbers under the age of 65 years. 18th November 2005 4. 5. Date of last inspection 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 DS0000044748.V329760.R01.S.doc Version 5.2 Page 5 The home charges between £390.00 and £440.00 per week. Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. An unannounced inspection took place on a day in January over approximately 8 hours. The inspection looked at the majority of standards and all the key standards. During the inspection the inspection the inspector spoke to six residents, one member of staff, the manager and service manager of the home, two relatives and a health professional. The inspector looked at three residents care files and two staff files, sampled the medication administration, looked at records of the maintenance of the building and toured some areas of the building. Following this inspection a routine Health and Safety visit was carried out of the kitchen area and this was added to this report. The home had received no complaints since the last inspection and the Commission had not been involved in any complaints or adult protection issues. The inspectors received comment cards from 6 relatives and 6 residents the comments were positive and residents thought almost consistently that they always received a good service. What the service does well:
The home collected good information on residents and this informed the care plans that they made for residents. The home collected information on residents’ health conditions and put that information on the residents care files for staff to refer to. This was commended as excellent practice. The home writes clear care plans that instruct staff how to care for residents. The detail in the care plans helped residents retain any abilities they retained for example one resident was encouraged to retain the skill of cleaning their dentures another to wash and dress themselves but having assistance with buttons. This is good practice. The staff and manager of the home have a problem-solving attitude to issues that are of concern to residents. Residents were helped to take part in the solution to their problems and this is commended. The home showed that the instructions in the care plans were followed for example a resident that needed drinks of cranberry juice had these available to them on the day of the inspection. Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 7 Residents’ health and hygiene needs were met. Residents were referred appropriately to health professionals when needed. One District Nurse spoken to thought the home was professional in the way dealt with health professionals always ensuring that the resident was introduced to the health professional that was there to treat them. Residents were happy with the care they received. Residents on the day of the inspection had their hygiene needs met and were dressed appropriately in well laundered clothes. A number of residents attended the hairdresser on the day and female residents had their nails painted if they wished. During the day the inspector was pleased to see that residents and staff were interacting well with staff talking some time with individual residents. Relatives comment cards suggested that relatives were welcome in the home and relatives spoken to confirmed this. Residents were happy with the amount of activities and the choice of meals two residents saying that the meals were very good. Residents felt safe in the home and the records of residents’ meetings showed that residents felt able to raise concerns. Further recording of small concerns would assist the home with their quality assurance. The home was decorated and furnished to a high standard and was fresh and clean on inspection. All the appropriate maintenance of the building services such as fire gas and electric safety were undertaken. These measures ensured a safe and pleasant environment for residents. The home had appropriate levels of staff to meet the current needs of residents. Appropriate checks were undertaken before staff were allowed to work in the home. The manager showed that she was able to manage the day-to-day running of the home and had a good knowledge of the residents. The homes paper records were well organised and information was easily retrieved on request. What has improved since the last inspection?
The home had ensured that residents had risk assessments to ensure that residents had appropriate nutrition and had looked at risk assessments for symptoms of illnesses since the last inspection. The home had improved the number of staff that had completed the basic NVQ level 2 course in care and this now exceeded the standard of 50 . The home was actively looking at ways of providing some quality assurance system and had some methods of collecting residents views, and auditing their service that could be built on.
Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 8 The home was showing that they had progressed on all previously made requirements. 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. The summary of this inspection report can be made available in other formats on request. Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 9 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 Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home undertakes thorough assessments of residents’ difficulties and abilities to ensure that these needs can be met on residents’ admission to the home. EVIDENCE: Three residents care files were looked at in detail. Residents admitted into the home had the benefit of a preadmission assessment. Where residents had assessments from a social worker these were included in the records. Assessments contained enough information to help the home judge if they could provide the appropriate care for residents coming in to the home. The home was aware of the necessity of sending a formal confirmation in a letter that the home could meet the residents needs but had not had a recent admission to put this into practice. The home collected good information about resident’s abilities, their disabilities and their preferences of daily routine. This information collection helped the home plan individual care for the resident. For example a resident’s
Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 11 assessment said that they liked to undertake their own oral care and could manage to dress but had problems with buttons. The home collected information about this and followed this through to the care plan. The care plan told staff to remind the resident to clean their dentures and staff were instructed to give assistance with buttons. This helped the resident retain some of their independence and life skills. As well as collecting details of residents’ health conditions the home also researched these conditions and the information was placed on the residents file so staff could familiarise themselves with the details. This is good practice and is commended. One resident had some short-term memory loss, which caused them concerns about the timetable for the day and what they should be doing. The home was able to put into place measures that reassured the resident and this is commended. One resident had concerns about their health and the home arranged, as the resident wished, a meeting to discuss their health. The home showed that they were aware of resident’s communication difficulties and where necessary had plans in place to assist residents to be involved in their care. Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had developed detailed care plans for residents that gave clear instructions to staff and this ensured good care for residents. Risk assessments needed further monitoring to ensure that changes could be made in a timely way however residents’ health care needs were met in a way that protected residents’ dignity. Medication administration needed further checking to maintain a consistently good record of the medication given and to protect residents’ health. EVIDENCE: Care plans were well written and detailed enough to instruct staff how to care for each resident. For example where residents had incontinence the sizes of pads the individual resident used during the day and at night were recorded. One record sampled had good detail on how to provide the personal hygiene needs of a resident it stated ‘Needs back and lower body washed, give flannel and will wash face and hands.’ ‘Assist with socks and trousers.’
Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 13 The home ensured that risk assessments were completed for the likelihood of residents getting pressure areas, having poor food intake and moving and handling. Where residents were seen to be at risk of poor food intake the residents sampled had either gained weight or a referral had been made to their GP. A number of the residents had high risks in this area and their risk assessment had not been reviewed regularly enough to ensure that that the risk remained controlled. The home also undertook risk assessments where a resident’s condition had risks for example one resident had recurring problems with cystitis and part the risk lessening methods was to provide cranberry juice. The home showed that this instruction was followed and the inspector found a glass of cranberry juice next to the particular resident. The home undertook smoking risk assessments but these could be more detailed to ensure that all areas of the resident’s smoking pattern is considered and planned for. Residents’ records showed that residents were given assistance to shower and bath regularly and as much as their health condition and cooperation allowed. Residents on the day of the inspection had their personal hygiene needs met. One resident said ‘all the staff are very good.’ A number of the female residents had their nails painted and a number of residents had opted to have their hair care attended to by a hairdresser. Residents appeared to be wearing their own clothing that fitted well and had been well laundered. Residents that need the services of health professionals such as district nurses, GPs, opticians and so on are referred for this assistance. A district nurse, spoken to at the time of the inspection, had no concerns about the home’s practice. She stated that the home always found the resident ensured introductions were undertaken. The medication administration in the home needed improvement. The home manager stated that she had noted some improvements that were needed at an audit and that a meeting had been arranged for the day of the inspection to discuss with the staff. The inspector found that medication was not always auditable especially when the dose was variable for example when 1 or 2 tablets of a medication could be given. Medication was not always signed for that had been given and medication had not always been given that had been signed for. There were gaps of signatures on the Medication Administration Record (MAR). One medication had to be given dependent on the resident’s health condition on each day and this needed some notes to ensure this is given consistently. All medication that is given ‘as required’ needs a written protocol to ensure that they are given safely. The home ensured that copies of the prescription were kept with the MAR, there was a photograph of the resident with the MAR and medication was signed in to the home and on the MAR charts. These checks ensure that medication is given to the right person and accounted for.
Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 14 Medicinal creams were not always being signed as administered and the manager needs to look at a way of ensuring that staff comply with this. A number of the staff were undertaking the administering of medication course. The inspector witnessed good interactions between staff and residents. For example one resident was having banter with a member of staff and was still chuckling about it an hour later. Another resident was guided down a corridor and you could hear the resident and the staff member singing. Staff were observed getting to an appropriate height level of residents when they talked to them and this was good. One relative spoke of how easy it was to relax in the home and how the staff were approachable. Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes arrangements for activities, visitors and meals were good. Residents were able to have choices in these areas and this enhances their lives. The home should undertake the food risk assessment process and carry out any findings following this process. EVIDENCE: In the daily records there was some evidence of activities being offered however these were a little sporadic and needed to show what residents have had the opportunity to do. Residents were seen in the lounges watching television, reading and so on. A recent resident meeting discussed options of going to a farm and for residents to have the benefit of a massage. The home organise a visit from progressive mobility twice a month. Relatives spoken to on the day of the inspection said they were happy with the care that the home provided. They said that they felt relaxed in the home and could talk to the staff. One comment card from a relative said ‘We are often impressed not just by the care given but by the loving and wise way it is Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 16 given.’ Another comment card said ‘The staff are very pleasant and helpful.’ ‘It is one of the best (homes) that I visit. It is clean and tidy’. Residents were seen to have freedom of movement in the home. Residents had their walking aids next to them. A number of residents walked from lounge to lounge or popped into the office throughout the inspection. One resident’s notes said ‘…… was in the office today eating biscuits and chatting to staff.’ The inspector joined three residents for a lunchtime meal and had the choice of either shepherds pie or gammon. The shepherd’s pie was well cooked and nicely presented and accompanied by roast potatoes broccoli and cauliflower. One resident had some problems eating the gammon but said the meal was good. There was a choice of a cooked pudding and cold or fruit. The home needed to ensure that fruit was presented in a way, which is easy for residents to eat if they choose this as pudding. All of the residents said that they got a choice of meal not only at lunchtime but also at breakfast and tea. One resident on the table said ‘The meals are very good here.’ The home supplied four weeks of menus these that showed a good range of food on offer. The home supplies soup and sandwiches on a teatime however on three or four times a week they also offer a cooked meal like lasagne so that residents do not get bored with the choices. A residents meeting record showed that residents thought that the meals were good. A Health and Safety food safety visit took place following the inspection and before this report was written. The home needed to ensure a full hazard analysis of food was undertaken and some replacement chopping boards needed to be purchased. Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home showed that they were concerned with the happiness and safety of residents and this showed in the residents satisfaction with the home. EVIDENCE: The home had no complaints recorded since 2003 and the Commission had received no complaints about the home since their last inspection. The home had residents meetings but these were not held regularly. The home had issued questionnaires but these tend to rely or residents being able to remember issues and the inspector discussed other ways residents concerns could be collected as part of the quality assurance system. The Commission has not had any adult protection investigations with this home. The home has a copy of the multi agency guidelines on adult protection. The inspector found that in the staff cloakroom there was a poster detailing the staff responsibility to report adult protection issues and this is commended. Residents spoken to felt safe. Comment cards received suggested that residents were aware of who they could talk to about their concerns. Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and fresh on inspection and furnished and decorated to a high standard this makes a pleasant environment for residents to live. Although there were some issues that needed resolution on the day of the inspection the manager was able to demonstrate that these were in hand as part of ongoing improvements to the home. EVIDENCE: The inspector undertook a tour of the building looking at some of the bedrooms, the laundry and the communal areas. The home was decorated and furnished to a high standard. Bedrooms were decorated in modern fresh basic colours and residents were able to add their ornaments and some furniture to make them more individual to their tastes. A number of residents had done this. The home had replaced furniture in the
Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 19 bedrooms and where this had been done wardrobes had been attached to the walls some of the older wardrobes needed attaching so they could not be pulled over accidentally. One lounge was not in use and this was noticeably colder than the other lounges. The home were trying to follow up a problem thought to be with a washing machine but may have been with the heating at the time of the inspection. The toilet connected to this lounge has a door to outside and although this door has frosted glass residents may feel exposed by it and some screening of the door is recommended. The carpet in this lounge despite its newness had not withstood its use very well and looked quite stained. The manager stated that this carpet was to be replaced. One shared room needed the privacy curtain extending so that both residents could have the benefit of privacy if they were unwell. The bedding and mattresses checked were of good quality and serviceable one mattress needed turning to ensure that it remained even. Residents that needed equipment to assist them had the benefit of this. Residents spoken to knew how to summon help in an emergency. The home was clean, tidy and fresh on the inspection. The home had a safe system of laundry to ensure the risks of transfer of infection were small. The inspector recommended that the purchase red alginate bags would enhance this. The home audits their infection control standard regularly. Bournville Grange DS0000044748.V329760.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing in the home was appropriate to the needs of the residents, with residents saying they get help when needed. The process of recruitment and selection of staff was good and this protects residents. The home has the majority of care staff trained to a basic level of NVQ2 in care however some mandatory training was not be completed in a timely way and this can mean that the staff are not aware of current good practice. EVIDENCE: The homes staffing rotas showed the home has appropriate levels of staff to meet the needs of residents. The staff do not routinely work excessive hours and this means that residents have the benefit of staff fit enough to work. Staff have a senior member of staff available during daytime shifts and at night a senior member of staff is on call for consultation. The home employs ancillary staff of cooks and domestics. Almost 60 of care staff have achieved the NVQ2 in care and this exceeds the standard.
Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 21 The inspector looked at two staff files. The home has not taken on any new staff since the last inspection. The files showed that the home had a process of recruitment that included completion of an application form, references and appropriate Criminal Records Bureau checks and Protection of Vulnerable adult checks before staff could start work. The inspector did not see a new member of staff induction process but this will be looked at the next inspection. Staff were given a contract of employment when they started at the home. The home supplied a matrix of staff attendance or achievement of mandatory courses. This showed that staff had good attendance on first aid, food hygiene and adult protection but that other mandatory courses of health and safety, moving and handling and infection control had poor levels of attendance. The home was not demonstrating that all staff have fire training at least 6 monthly. Bournville Grange DS0000044748.V329760.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements in the home ensured that the home was run in the best interests of the residents. Residents could be assured that the routine maintenance of services was undertaken to safeguard residents. The home needed to ensure that independent inspection of lifting equipment was undertaken as confirmation that there are no faults. EVIDENCE: The manager of the home has many years experience in the care of older people. She has almost completed the Registered Managers Award and has NVQs level 2 and three in Care. She has a good knowledge of the residents in
Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 23 her care and showed from the care planning and problem solving of issues that arose before and during the inspection that she is capable to undertake this role. The proprietor and service manager visit the home regularly. The service manager provides the Commission with reports of their monthly visits in which she records the outcomes of speaking to a number of residents and staff. The organisation is looking into pulling together a quality assurance system. At present the home as some elements of a quality assurance system that they could be built upon these include the monthly visits by the organisation and resident questionnaires. Audits of medication, the building, training, falls, accidents, infections and so on should lead to a yearly overview and report of the service and an action plan for improvement. The home manager stated that the home does not hold money for residents. Residents either hold money themselves or more usually relatives hold money and provide the items residents need. The home invoices residents or relatives for hairdressing, chiropody and so on after they have had these services. The homes records were well ordered and information could found easily. The homes maintenance and inspection contracts were looked at for key services such as gas and electric supplies and equipment. These were in order. The home’ fire safety records were up to date and regular checks were being undertaken. The home had revisited their fire procedure following an alarm being raised and the front door remaining locked. The home had a Legionella water safety certificate and the relevant companies had maintained the home’s lifting equipment. An independent inspection was required to ensure that a thorough examination had been completed of lifting equipment including the passenger lift. Bournville Grange DS0000044748.V329760.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 4 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 3 2 Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 25 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 OP8 Regulation 13(4)(c) Requirement Risk assessments that include high level of risk must be reviewed at least monthly to ensure the risk continues to be minimised. Risks such as smoking need to be in enough detail to show where the in the process the risk is and so that effective steps can be taken to minimise them. The Medication administration records (MAR) must be completed when medication is given, and when not given an appropriate reason for them not being given supplied. Variable doses must be indicated on the MAR to ensure that medication is auditable. Medication given ‘as required’ must have a protocol for administration to ensure that medication is given in a consistent way. Medicinal creams must be signed for when applied on either the
Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 26 Timescale for action 31/03/07 2. OP9 13(2) 31/03/07 3 OP15 13(3) 4. OP19 13(4)(c) 12(4)(a) MAR or specific cream chart. The home must ensure that they have a food hazard risk assessment and adhere to recommendations made by the Food Safety Department. All wardrobes must be fixed to the wall to prevent them being overturned. The home must continue the issue of heating in the identified lounge. The home must ensure that the privacy issues identified are addressed. Induction training for staff must be completed within twelve weeks of them commencing their employment. (Previous time scale of 14/07/05 not assessed for compliance at this visit. No new staff so not assessed.) The home must ensure that staff achieve appropriate levels of training in Moving and handling, first aid and fire safety. 31/03/07 31/03/07 5. OP30 18(1)(a) 01/04/07 6. OP31 9(2)(b)(i) The manager must be qualified to NVQ level 4 in management and care or the equivalent by 2005. The home must have effective quality assurance and quality monitoring systems in place, based on seeking the views of the residents. (Time scale of 01/04/05 partly met) The manager must ensure that staff receive a minimum of six supervision sessions per year. (Previous time scale given 01/08/05 not assessed for compliance at this visit.)
DS0000044748.V329760.R01.S.doc 01/04/07 7. OP33 24(1)(a) (b) 01/04/07 8. OP36 18(2) 01/04/07 Bournville Grange Version 5.2 Page 27 9. OP38 23(2)(c) There must be an independent inspection of lifting equipment including the passenger lift. A copy of the certificate must be sent to the Commission by 30/04/07 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 OP15 Good Practice Recommendations It is recommended that the home look at the ease of eating fruit for residents and prepare it when required. Bournville Grange DS0000044748.V329760.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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