Inspection on 25/10/05 for Bretby House

This inspection was carried out on 25th October 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bretby House 16/04/08

Bretby House 18/10/07

Bretby House 19/04/07

Bretby House 16/10/06

Bretby House 06/06/06

Bretby House 09/02/06

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 Bretby House 253 Boldmere Road Wylde Green Sutton Coldfield West Midlands B73 5LL Lead Inspector Brenda O’Neill Unannounced Inspection 25th October 2005 09:05 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 Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 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. Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bretby House Address 253 Boldmere Road Wylde Green Sutton Coldfield West Midlands B73 5LL 0121 373 6562 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) Care First Class (UK) Ltd Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. The home is registered to accommodate to 24 older people. Provide assisted bathing/showering facilities on the first and second floors of the home within twelve months of registration. Provide additional dry goods storage space within nine months of registration. Provide a sluice facility within six months of registration. Provide guards of covers to all radiators within the home within six months of registration. Replace or relay the uneven garden path to improve safe access to the garden within six months of registration. In addition to the manager and ancillary staff a minimum of three care staff must be on duty during the waking day and two care staff on night duty. 24/02/05 Date of last inspection Brief Description of the Service: Bretby House is a large, extended house with parking space available. It is close to public transport routes with Wylde Green station being a short walk away. Boldmere shopping centre is also close to the home. The home provides care and accommodation for up to 24 older people. Accommodation for the residents is spread over three floors with a mixture of single and double rooms, some of which have en-suite facilities. There are several toilets, one shower room and three bathrooms in the home, however not all of these allow for full assistance from staff. Communal areas are located on the ground floor and comprise of one large and one smaller lounge and a dining room. Also located on the ground floor are the kitchen, laundry, office and staff facilities. There is a large and well maintained garden to the rear of the home that is accessed via a ramp. Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out by two inspectors over one day in October 2005 and was the first of the statutory inspections for 2005/2006.The inspecting pharmacist visited the home at a later date to inspect the medicine management in the home. The home had changed hands in September 2005 and this should be taken into account when reading this report. During this visit a tour of the home was carried out, three resident files were sampled as well as other care and health and safety records. The inspectors spoke with the deputy manager, proprietor, eight of the nineteen residents and briefly to two staff on duty at the time. What the service does well: What has improved since the last inspection? What they could do better: Care plans and risk assessments for the residents needed to be updated and individualised to ensure they included sufficient detail for staff to be able to meet the identified needs. When drawing up care plans more attention needed to be paid to the individual’s likes dislikes and preferences. Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 6 All residents needed to have manual handling and personal risk assessments that included details of any manual handling techniques to be used by staff and actions to be taken to minimise any identified risks. Although medicine management in the home had improved further improvements were needed to ensure it was entirely safe. There needed to be some consultation with the residents about their preferred leisure time activities and actions taken to offer some stimulating pastimes. Records of food being served to the residents needed to be kept to evidence that that they were receiving a balanced diet, that choices were being offered and that any special diets were being catered for. The records being kept for the management of the residents’ finances needed to be improved and include where income had come from, receipts needed to be available for all expenditure and there needed to be two staff signatures where residents were unable to sign. Several issues in relation to the health and safety of the residents and staff were raised at this inspection that needed to be addressed as a matter of urgency including, fire prevention, the temperature of the water in the shower, unguarded radiators and fraying carpets. The assisted bathing facilities in the home needed to be improved to ensure they were adequate for the needs of the residents. The registered person needed to ensure that a manager was appointed for the home as soon as possible so that residents were assured there was someone who was responsible and accountable on a day-to-day basis for the running of the home. 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. Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 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 Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 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 and 5. The needs of prospective residents referred to the home via social care and health were being appropriately assessed and the staff were able to determine if they could meet the individuals’ needs. EVIDENCE: Three residents’ files were sampled during this inspection. They included evidence that social workers had undertaken their assessments prior to admission to the home and drawn up their initial care plans. There was also evidence of a 28-day review being carried out after the trial period to establish if the placement was suitable for all concerned. The deputy manager stated that residents were able to visit the home prior to admission but there was no documentation in relation to this. It was strongly recommended that the pre admission visit is documented and that this gives an outline of how the day went, how the prospective resident mobilised around the home and if they liked the home and so on. Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 9 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 and 9. Care plans and risk assessments needed to be individualised and updated to ensure they included sufficient detail to enable the residents’ needs to be met and consideration was given to their likes, dislikes and preferences and ensure all identified risks were minimised. The systems for medicine management within the home have improved since the last pharmacist inspection. The manager must ensure that all the medicines are administered as prescribed at all times. EVIDENCE: Three care plans were sampled during the course of the inspection. The care plans being used were generic with a space for additional comments. These were not individualised and did not include enough detail of the residents’ needs or of how these needs were to be met by staff. Comments on the care plans included such statements as, under diet, note any dislikes/allergies and offer an alternative whereas any dislikes or allergies should be detailed on the care plan to ensure staff are aware of them. Another statement included was, use pads if prone to incontinence, this should be known and detailed on care plans as to how continence is managed including what pad size. There were activities for daily sheets but again these were very vague and stated such things as, needs a little help and supervision with washing and dressing, and Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 10 enjoys her food. There was no information as to what the residents were able to do for themselves, their likes, dislikes or preferences, for example, one resident’s notes indicated she liked to be woken between 9 and 9:30am but she was being given her breakfast by the night staff who went off duty at 8:00am. There was no evidence that the residents had been consulted about their care plans or that they were reviewed monthly. There was no evidence of any manual handling risk assessments on any of the files. It was evident from other records that one of the residents was not weight bearing but without a risk assessment staff would have been unclear about the handling methods to be used. One of the residents had a personal risk assessment in relation to an infection and this detailed how staff were to manage this and it had been initialled by all staff indicating they had read it. There was no evidence of any other personal risk assessments on the files sampled even though there were risks evident, for example, an overcrowded bedroom, one resident had had a very raid deterioration in their sight however there were no risk assessments in place indicating what could now be hazardous for the individual. There were falls and nutritional risk assessments on all files but the action plans for these were generic and all the actions did not apply to the individuals concerned. No tissue viability assessments had been undertaken and there was evidence that some residents spent long periods of time sitting down and would be vulnerable to pressure sores. Daily records evidenced that generally health care needs were identified by staff and followed up and there was evidence of visits from the G.P., chiropodist, district nurse and hospital admissions. Some discrepancies were noted in the written information in relation to the general well being of the residents, for example, night staff were recording for several nights that a resident had slept well then day staff recorded that she had not slept well the past few nights. It was also noted that one resident had complained of not feeling well for a few days and then there were visible signs that the person was unwell and the doctor was not called until the day after this recording. Daily records did evidence that personal care needs were being met and it was noted that the care assistants were attentive to the appearance of the residents and ensured their clothing was comfortable. The inspecting pharmacist visited the home. Her findings are detailed below: The medicines administered from the Monitored Dosage System dispensed by the pharmacist were correct. Medicines dispensed in bottles and boxes were not routinely administered as prescribed. The deputy manager was awaiting a medication trolley to store and transport medicines to the service users which should improve the service. All medicines received into the home were thoroughly checked in and hand written Medicine Administration Record (MAR) Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 11 charts were well written. All drugs were auditable which was commended. Staff drug audits did not take place but the deputy manager was keen to implement these. The home did not have a Controlled Drug cabinet and Controlled Drugs were not stored correctly at the time of the inspection. Cream and ointment management was very poor. Many were found on the premises that were unlabelled or out of date. These were removed at the time of the inspection. The medicine refrigerator was incorrectly sited in the kitchen and the maximum, minimum and current temperatures were not read on a daily basis to confirm correct storage of medicines within. Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15. There needed to be some consultation with the residents about their preferred leisure activities and action taken to ensure social needs were being met. Residents were generally satisfied with the catering arrangements at the home. EVIDENCE: The residents spoken with were content and did not feel there were any rigid rules or routines in the home. However it was noted that all residents are woken and given their breakfasts by the night staff. Residents did state they could have a lie in after breakfast but it was strongly recommended that residents are consulted about their preferred waking times and when they would like their breakfast. On the day of the inspection residents were observed spending time in their rooms, reading the newspaper, chatting to each other and taking part in an exercise session. There were board games and books available in the home but there was no documented evidence of any activities facilitated by staff. This issue was discussed with the deputy manager who stated there was not much going on in the home of late. There needed to be some consultation with the residents about their preferred leisure time activities and actions taken to offer some stimulating pastimes. Residents spoken with stated they were satisfied with the catering arrangements at the home. They confirmed that if they did not like what was Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 13 on the menu they could have an alternative. Staff went around prior to teatime and asked the residents what they wanted and a record of this was seen. The menus seen needed to be more detailed and include the vegetables and types of potatoes to be served to evidence a variety was being offered. There also needed to be a record of foods being served to the residents at all meals to evidence they were receiving a balanced, nutritious diet and that any special diets were being catered for. There was a list of special dietary needs in the kitchen but no evidence to support these had been adhered to. It became apparent after discussion with the cook and the deputy manager that the supply of fresh milk to the home was not enough for the numbers of people being catered for. Powdered milk was being used on a regular basis to supplement this. This was not acceptable practice and powdered milk should only be used as a stand by. The dining room was bright and generally well furnished and decorated however there was only enough seating for 16 people. The inspectors were informed not all residents chose to eat in the dining room and some had their meals in their rooms. There needed to be enough tables and seating available for all the residents that may be in the home at any one time as residents may change their minds and want to sit at a table to eat. Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. Requirements from the previous report have not been brought forward to this report as they were made to the previous manager. The standards will be assessed at the next inspection. EVIDENCE: Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 and 26. The home was generally well maintained and the residents appeared comfortable. Several issues needed to be addressed to ensure the home was safe for the residents. EVIDENCE: The location and layout of the home was suitable for its stated purpose and it was generally well maintained. At the time of the inspection some of the fire doors were wedged open and several wedges were seen in the residents’ bedrooms indicating that they were also at times wedged open. Wedging fire doors open is dangerous practice and the registered person needed to ensure this stopped and alternative solutions explored if residents wanted their doors left open. There was adequate communal space at the home with two lounges and a dining room. One of the lounges had a television, video and music centre, the other lounge tended to be used more as a quiet area for the residents. This lounge appeared quite overcrowded with chairs and furniture. It was strongly Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 16 recommended that it was reorganised and any excess furniture removed to give it a more homely feel. It was noted that the vinyl covering on some of the armchairs in the larger lounge had split and as it was quite brittle could have damaged the residents’ skin. These armchairs needed to be removed and replaced. There was a large well maintained garden to the rear of the home that was accessible to the residents. One of the conditions of registration for the home was that the uneven path must be replaced or relayed to improve safe access to the garden. There were adequate numbers of toilets throughout the home and some were large enough for staff to offer assistance. In several of the toilets the extractor fans were not working and this needed to be addressed. The home had three bathrooms and one shower room. The inspectors were informed that the medic bath was never used, the shower had a large step up shower tray and one bathroom had only a domestic type bath. There was one bathroom on the first floor that had a bath hoist seat but this room would not have allowed for full assistance from staff. One of the conditions of registration for the new proprietors is that assisted bathing/showering facilities are provided on the first and second floors of the home. At the time of the inspection the medic bathroom was very cluttered and being used for storage. This made the room hazardous for any residents who wanted to use the toilet in there. The built in cupboard in this bathroom was being used to store food, which was not appropriate, and again this was a condition of registration that alternative space for this must be found. The flooring in the bathroom on the first floor was worn and split and a potential tripping hazard and in the majority of the bathrooms and toilets the vinyl was not sealed around the edges and needed to be addressed. There were some aids and adaptations throughout the home to assist those residents with mobility difficulties including shaft lift and a ramp for going into the garden. There was only one very small handrail in one of the ground floor corridors and although there were wheelchairs available these were being used without foot rests which was dangerous practice. As stated previously the assisted bathing facilities in the home were inadequate. Bedrooms varied in size and the majority of the required furnishings and fittings were evident. The majority of the rooms had only one chair and there was not always access to bedside lighting. The bedrooms should be audited for furnishings and fittings against the National Minimum Standards and any shortfalls rectified. All rooms had a lockable facility and residents were able to have keys to their bedroom doors if they wished. Several of the bedrooms had carpets that were well worn and in need of replacing and at the doorway of several of the bedrooms the carpet was fraying and a potential tripping hazard. Bedrooms were personalised to the occupant’s choosing. There was central heating throughout the home however the radiators had not been guarded. The inspectors were informed that all hot water outlets had Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 17 thermostatic mixer valves fitted however the water temperatures to the shower was well in excess of 43 degrees and needed to be addressed. There was also a small amount of hot piping in the ground floor toilet that needed to be boxed in. All bedrooms were naturally ventilated and window restrictors had been fitted where appropriate. The home was generally clean and odour free, however some improvements were needed in the kitchen. The fridge and freezer both needed to be cleaned particularly around the seals. Both seals were broken and the fridge and freezer needed to be replaced or repaired as soon as possible. The dishwasher was not working and needed to be repaired or replaced. Some of the floor areas, shelving and cupboards in the kitchen needed to be thoroughly cleaned. Fridge and freezer temperatures were being recorded on a daily basis. To further improve infection control in the home: • All cotton towels and hard soap needed to be removed from all communal bathing/showering, toilet facilities and from the kitchen and staff toilet and all provided with liquid soap and disposable towels. • A new bin needed to be provided for the clinical waste with a tight fitting lid. • All wheelchairs needed to be thoroughly cleaned. The washing machine at the home did not have a sluice cycle, one of the conditions of registration is that a washing machine with a sluice cycle is installed in the home. There were also numerous commodes being used in the home and the effective cleaning of the commode pots appeared to be an issue therefore the home should at their earliest opportunity install a mechanical commode pot washer/disinfector. Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 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 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 Good staffing levels were being maintained at the home. Several staff had worked there for a considerable amount of time which was good for the continuity of care of the residents. EVIDENCE: Good staffing levels were being maintained at the home that complied with the condition of registration. On the day of the inspection there were three care assistants, one domestic and one laundry assistant and a cook on duty. In addition to this the deputy manager was also on duty and her hours were super nummery to the rota. At weekends the number of care assistants increased by one as there was no laundry assistant and there was always a senior care on duty. The home was fully staffed at the time of the inspection. Several of the staff had worked at the home for a considerable amount of time, which was good for the continuity of care of the residents, and friendly relationships were evident. The residents spoken with were very positive in their comments about the staff team. Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 35 and 38. A manager needed to appointed for the home so that the residents were assured there was someone who was responsible and accountable on a day-today basis for the running of the home. Several improvements were needed in the home to ensure the safety of the residents and to ensure the home met with the National Minimum Standards. EVIDENCE: On the day of the inspection the deputy manager was managing the home. She had worked there for many years and had a good knowledge of the resident in the home. The responsible individual who had been recently registered was overseeing the management of the home until a manager was appointed. The deputy manager did not want the additional responsibility of being the registered manager. Both the proprietor and the responsible individual were aware of this and knew they had to appoint a manager for the home to ensure someone was available to take management responsibility on a day to day basis. Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 20 Numerous issues were raised that needed to be addressed to ensure the home meets the National Minimum Standards and these were discussed with the proprietor at the time of the inspection. The home was managing the finances for several residents for every day needs. The records were sampled and found to be inadequate. The records detailed income but not state where it had come from, expenditure was entered but there were inadequate or no receipts available and no one was signing the records. All the balances checked were correct. The deputy manager had had responsibility for the monies since the previous manager left. She was advised that records must include: where income had come from, receipts needed to be available for all expenditure and there needed to be two staff signatures where residents are unable to sign. Several issues in relation to the health and safety of the residents and staff were raised at this inspection including the guarding of radiators and fire prevention. It was also noted that the emergency lighting was two weeks overdue for its monthly check but the fire alarm was being checked weekly. There was a record that staff had received fire training but it was not clear if this included a drill or was just a drill. There was evidence on site that the majority of the equipment in the home had been serviced including, gas equipment, bath hoist, portable electrical appliances and the lift. The electrical wiring certificate was out of date and there was no evidence that the water system had been checked for the prevention of legionella. Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 2 1 2 X 2 1 2 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 1 X X 2 Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Previous requirements were given to the former owner. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1)(2) (a)(b)(c) Requirement All residents must have care plans that detail how all their individual, current needs in respect of their health and welfare are to be met by staff. Care plans must be cross referenced to any risk assessments undertaken to ensure both documents agree. There must be evidence that the residents or their representatives have been consulted about the care plans. Care plans must be updated as the needs of the residents change. 2 OP7 13(5) All residents must have manual handling risk assessments that detail the actions to be taken by the staff in the event of a fall if the resident is not injured. All residents must have personal risk assessments that detail how any identified risks are to be minimised. If no risks are DS0000064275.V259866.R01.S.doc Timescale for action 01/01/06 01/12/05 3 OP7 13(4)(c) 01/12/05 Bretby House Version 5.0 Page 23 4 OP8 12(1)(a) 5 OP8 12(1)(a) identified this must be documented. All residents must have tissue viability assessments and actions must be taken to minimise any identified risks. Staff must ensure that what is written in daily records is a true reflection of the residents’ well being. Doctors must be consulted in a timely manner when residents are unwell. Regular staff drug audits must take place to assess staff competence in medicine management. Appropriate action must be taken when discrepancies are found The purchase of a Controlled Drug cabinet that complies with the Misuse of Drugs (Safe Custody) Regulations 1973 is required. All CDs must be stored within it. Two members of staff must sign the Controlled Drug register. Initials are inadequate. All external preparations must be labelled and the dated once opened. It is advised that these preparations are discarded 28 days from opening to reduce the risk of microbial contamination and to ensure regular reviews of cream applications are undertaken. 01/12/05 14/11/05 6 OP9 13(2) 04/11/05 7 OP9 13(2) 30/11/05 8 9 OP9 OP9 13(2) 13(2) 04/11/05 04/11/05 10 OP9 13(2) 11 OP12 16(2)(m) The medication refrigerator must 04/11/05 be located in the medication room and the maximum, minimum and current temperatures recorded on a daily basis to ensure that the medicines are stored within their product licences The residents must be consulted 01/01/06 DS0000064275.V259866.R01.S.doc Version 5.0 Page 24 Bretby House 12 OP15 17(2) schedule 4(13) about their preferred activities and action taken to ensure their leisure needs are met. The menus must detail all foods being offered including vegetables. Records of food served to the residents must be kept in sufficient detail to evidence that the diet is nutritious, choices are offered and any special diets are being catered for. The amount of fresh milk delivered to the home must be increased to prevent the routine use of powdered milk. There must be enough seating and tables available to accommodate all the residents at meal times. Fire doors must not be wedged open. The armchairs that have breaks in the vinyl covering must be removed and replaced. The uneven garden path must be replaced or re-laid. The ground floor bathroom must be cleared of all unused items. The manager must ensure that the toilet in the ground floor bathroom is accessible to the residents. All extractor fans must be in working order. Assisted bathing/showering facilities must be provided on the first and second floors of the home. Additional dry goods storage space must be provided. The flooring in the first floor bathroom must be made safe. The vinyl flooring in the bathrooms and toilets must be DS0000064275.V259866.R01.S.doc 01/12/05 13 OP15 16(2)(i) 14/11/05 14 OP15 23(2)(g) 01/12/05 15 16 17 18 OP19 OP20 OP20 OP21 13(4)(c) 13(4)(c) 13(4)(c) 13(4)(c) 25/10/05 01/12/05 20/03/06 27/10/05 19 20 OP21 OP21 23(2)(c) 23(2)(j) (n) 23(2)(l) 13(3)(c) 23(2)(b) 14/12/05 20/09/06 21 22 23 OP21 OP21 OP21 20/06/06 27/10/05 01/12/05 Bretby House Version 5.0 Page 25 24 OP22 13(4)(c) 25 OP22 23(2)(n) 26 27 28 OP24 OP24 OP24 13(4)(c) 16(2)(c) 16(2)(c) (p) 29 OP25 13(4)(c) 30 31 32 OP25 OP25 OP26 13(4)(c) 13(4)(c) 13(3) 33 OP26 13(3) adequately sealed around the edges. Wheelchairs must not be used without footrests unless specifically detailed in a care plan. An audit of the aids and adaptations available in the home must be undertaken and additional equipment fitted as necessary. Any carpets that are fraying and a potential tripping hazard must be addressed. Any worn bedroom carpets must be replaced. The furnishings and fittings in the bedrooms must be audited against the National Minimum Standards and shortfalls rectified. The registered person must ensure the hot water temperature to the shower is not in excess of 43 degrees. All radiators must be covered or guarded. The hot pipe work in the ground toilet bathroom must be boxed in. There must be liquid soap and disposable towels available in all toilets, bathrooms, laundry and kitchen and all cotton towels and hard soap removed. Any badly rusting commodes must be disposed of. All wheelchairs must be thoroughly cleaned. A new bin must be provided for the storage of clinical waste with a close fitting lid. All work surfaces, cupboards, flooring, fridges and freezers in the main kitchen must be kept 26/10/05 01/03/06 28/10/05 01/02/06 01/05/06 29/10/05 20/03/06 01/12/05 28/10/05 27/10/05 Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 26 34 OP26 13(3) & 23(2)(c) hygienically clean. The fridge and freezer must be repaired or replaced. The dishwasher must be repaired or replaced. A washing machine with a sluice facility must be installed in the home. A commode pot washer/disinfector must be installed in the home. The registered person must appoint a manager for the home. The registered person must ensure that where finances are being managed on behalf of residents that the records include: - Details of any income. - Receipts for any expenditure. - Two staff signatures for any transactions where residents are unable to sign. There must be evidence on site that the water system has been checked for the prevention of legionella. There must be evidence on site that the hard wiring in the home has been checked. The emergency lighting must be checked on a monthly basis. All staff must receive fire training and undertake fire drills every six months. Clear records of these must be maintained. 01/01/06 35 36 37 38 OP26 OP26 OP31 OP35 13(3) 13(3) 8(1) 13(6) 20/03/06 20/08/06 01/01/06 14/11/05 39 OP38 13(3) 01/01/05 40 41 42 OP38 OP38 OP38 23(2)(c) 23(4)(c) (v) 23(4)(d) 01/01/05 01/12/05 01/12/05 Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP5 OP12 OP20 Good Practice Recommendations It is strongly recommended that pre admission visits to the home are documented and include an overview of the day. It is strongly recommended that residents are consulted about their preferred waking times and when they would like their breakfast. It is recommended that the small lounge is reorganised and excess furniture removed. Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 28 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 Bretby House DS0000064275.V259866.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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