Inspection on 23/01/07 for Britannia Care Home

This inspection was carried out on 23rd January 2007.

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

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

Other inspections for this house

Britannia Care Home 03/07/08

Britannia Care Home 30/08/07

Britannia Care Home 16/05/06

Britannia Care Home 10/01/06

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Britannia Care Home 4 Thorn Street Girlington Road Bradford BD8 9NU Lead Inspector Mary Bentley Key Unannounced Inspection 23rd & 24th January 2007 09:30 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 Britannia Care Home DS0000061941.V317380.R03.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. Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Britannia Care Home Address 4 Thorn Street Girlington Road Bradford BD8 9NU 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) 01274 770405 Girlington Nursing Home Ltd Ms Shaheen Kauser Care Home 25 Category(ies) of Dementia - over 65 years of age (25) registration, with number of places Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2006 Brief Description of the Service: The home offers personal care and nursing care to older people and younger adults from a wide range of cultural backgrounds. It is situated in the Girlington area of Bradford, which is approximately 1 mile from the city centre. There is a very good range of amenities available locally including shops, public houses, churches, and mosques. The home is well served by public transport. Accommodation is provided on three floors, there are double and single rooms. None of the rooms have en-suite facilities. There are four communal bathrooms located on the first and second floors, and communal toilets are located throughout the home. The communal rooms are on the ground floor and consist of two lounges and a dining room/lounge. One lounge is a designated smoking area for residents. There is a passenger lift to all floors and a ramp for disabled access at the front of the home. There is a small parking area at the back and street parking is available. In January 2007 the owner told us the fees ranged from £394.00 to £425.00 per week. Hairdressing and the cost of outings are not included in the fees. Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 we made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate”, and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The last inspection was in May 2006 and there were 13 requirements. Following that visit some issues were referred to the local Adult Protection team. They have now been dealt with. We have made one additional visit to the home since May 2006 and have met with the provider to discuss proposed changes to the categories of registration. We agreed with the provider that we would meet following this inspection to discuss this matter further. I carried out this unannounced inspection over 2 days, spending a total of 11 hours in the home. During the visit I observed staff caring for residents, spoke to residents, relatives, staff and management, examined various records and looked at most parts of the home. Comment cards were not sent on this occasion, because the inspection date was brought forward and because the pre-inspection questionnaire was not returned before the inspection. There are 13 requirements following this inspection, three of them are carried forward from the last inspection. What the service does well: The home is friendly and relaxed. Visitors said they could visit at any time and were always welcome. Staff said it was like a “big family” and they particularly enjoyed the fact that both residents and staff come from a variety of cultural backgrounds. Daily routines are flexible and because there are not many people in the home staff have plenty of time to spend with residents. There was good interaction between staff and residents. Many of the residents are from an Asian background. Most of the staff speak a second language such as Punjabi or Urdu, and this helps to make sure that residents needs are understood. Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home sets out to provide a diverse and multi cultural service therefore the Statement of Purpose and Service User Guide must be made available in alternative formats so that they are accessible to a wide range of people. More work is needed on the care records to make sure that staff are given clear and detailed information about how to meet the needs of individual residents. To make sure that residents are protected some improvements are needed to the way that medicines are managed. Further improvements need to be made to the environment to make sure that it is suitably equipped to meet the needs of people living there. The use of CCTV inside the home must be reviewed with specific reference to the implications for residents’ privacy. Staffing levels will have to be kept under review to take account of increasing occupancy, day care, and residents’ changing needs. The procedures for employing new staff must be consistently followed to make sure that residents are protected. Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 7 The systems for monitoring the quality of the service must be developed so that people are given the opportunity to share their views of the service and to contribute to the development and improvement of the service. 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. Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3. Standard 6 does not apply to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs to do some more work on the written information provided to people using the service, or thinking about using the service, to make sure that they have detailed and accurate information about the range of services offered. The information must be presented in a format that is appropriate to the needs of residents and/or their representatives. EVIDENCE: Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 10 A Statement of Purpose and Service User Guide have been developed. They contain most of the required information. The views of people who use the service and a schedule of room sizes need to be added. These documents have been printed using blue and red ink and this may make it difficult for some people to read them. The Statement of Purpose does not make it clear that CCTV is used in some communal areas inside the home. If the home plans to continue using CCTV this must be made clear to people before admission so that they have the opportunity to make an informed decision about their privacy being compromised. The home prides itself on offering a diverse and multi cultural service therefore it is essential that these documents are available in alternative formats and languages. The home is in the process of giving residents a copy of the Terms and Conditions of residency. This should include information on the room to be occupied. It should also be available in alternative formats for the benefit of residents who are unfamiliar with the English language. At the last inspection there were concerns about the pre-admission assessment procedures and in particular about the admission of residents outside of the category of registration. There have not been any admissions since then. The manager has developed a pre-admission assessment form and an admission pack. This is intended to make sure that the home gets a detailed picture of the needs of prospective residents before admission. I discussed the pre-admission procedures with the manager before and during the visit. She said she understands the importance of completing comprehensive pre-admission assessments. Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been an improvement in this area. There is evidence that residents are being consulted about how their needs will be met. Further development of the care records is needed to make sure that care is delivered in a consistent way. Some improvements are needed to the medication system to safeguard the residents. EVIDENCE: Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 12 I looked at four sets of care records, two in detail. It was evident that a lot of work has been done to improve the care records since the last inspection. They were well organised and information was easy to find. There was evidence that residents’ assessments had been reviewed recently. There were care plans in place setting out how personal, health and social care needs would be met. Risk assessments had been done for falls, nutrition, continence and the risk of developing pressure sores and where necessary care plans were in place saying how these risks would be dealt with. There was evidence that the home was seeking advice from other professionals for example a dietician had been consulted about one resident who was losing weight. The resident’s weight was being monitored and a food chart had been in place until recently. Information was recorded about the resident’s dietary preferences. Some care plans were more detailed than others, one good example was a plan about sleeping that gave detailed information about the routine the resident likes to follow before going to bed. This is the standard that the home should be aiming for in all care plans, the use of phrases such as “encourage fluids” should be replaced with clear information saying what the desired daily fluid intake should be. Similarly for residents who are insulin dependant diabetics the care plans should state the acceptable upper and lower limits for blood sugar levels. The care plans are reviewed monthly. There was evidence that residents and/or their representatives are given the opportunity to contribute to the planning and reviewing of care. Two relatives said they are kept well informed about matters affecting their relatives’ care. There were no photographs of residents. There is a treatment room on the first floor but the medicines trolley is kept in the dining room during the day, if this is to continue it must be secured to the wall. The supplying pharmacist is taking unused medicines for disposal, the rules governing the disposal of medicines were changed in 2005, and the home must make alternative arrangements for the disposal of medicines. The prescriptions are sent directly from the GP surgery to the pharmacist, they should be returned to the home to be checked before they are sent to the pharmacy. It is also the home’s responsibility to sign the disclaimer on the back of prescription forms on behalf of residents’ who are unable to do so. Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 13 There is no system for keeping track of stock of medicines that are prescribed on an “as required” basis. The home must consult with the pharmacist about how to manage medicines for residents who are going out for the day or for weekends. The practice of secondary dispensing (removing medicines from their original containers) is not safe. No residents were administering their own medicines. There were no controlled drugs in use. The home does not have a policy on covert medication, (disguising medicines so that residents will take them); nurses said they do not do this. However, there should be a policy dealing with this practice and making it clear what nurses’ responsibilities are. During the two days I observed staff to be kind and respectful in the way they interacted with residents and visitors. Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 14 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 management and staff are working hard to make sure that the diverse social and cultural needs of people living in the home are recognised and met and that people are supported in exercising choice and control over their lives. EVIDENCE: Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 15 Daily routines are flexible and residents get up and go to bed when they want. Visitors said they can visit at any time and are always welcome, one person said it felt like “home”. There is no activities programme displayed. The manager said that because of the small number of residents and the fact that the residents have very different needs there is very little scope for group activities at present. However, she is aware that when there are more people in the home this aspect of the service will have to be developed. Some preparation has been done for this and a number of staff have attending training on providing activities in care homes. Each resident has a weekly activities plan in their care records but it wasn’t clear from the records whether these activities took place or not. There was evidence that the home is addressing the social, cultural, and religious needs of residents. For example the records showed what language residents spoke and/or understood. The staff are from multi cultural backgrounds and as well as English the majority speak at least one other language such as Punjabi or Urdu. One resident’s records showed that he prefers to spend his time on his own and does not want to mix with other residents, information provided by his family showed that this is his usual pattern of behaviour. Another resident goes out regularly, spending days or weekends at home with his family. A local advocacy group is involved with one of the younger residents and is supporting him in his application to get his own accommodation. There is information about residents’ religious needs. There is information about whether residents’ manage their own finances and if not who does this on their behalf. The home provides halal and non-halal meals; residents said they were happy with the food. There is a choice at lunchtime and at teatime, staff said that because there are only 7 residents people could more or less have what they wanted for tea. Information was recorded about residents’ dietary preferences. Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 16 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. People using the service are given information about how to make complaints or raise concerns. There are policies and procedures in place to make sure that residents are protected from abuse. EVIDENCE: Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 17 At the last inspection there were concerns about how complaints were dealt with and a number of concerns about care practices were identified. These were referred to the local Adult Protection team. Bradford Social Services contracts department was involved and admissions to the home were suspended. The home worked with the Adult Protection team and Social Services to address the concerns and these issues have now been resolved. The owner confirmed that Bradford Social Services has now lifted the suspension on admissions. The home has a suitable format for recording complaints; there have not been any further complaints since May 2006. Residents and relatives are given information about the complaints’ procedure during care reviews and this information is recorded. Information about the local Adult Protection team is displayed prominently in the home and staff are aware of the procedures to follow if they have any concerns. All the staff have had Adult Protection training. Britannia Care Home DS0000061941.V317380.R03.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, 21, 22, 24, 25 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made to the environment and overall the home provides a clean and comfortable place for people to live. More work is needed to make sure that the home is suitably equipped to meet residents’ needs. EVIDENCE: Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 19 The home was clean and tidy. There was evidence of an ongoing programme of upgrading the home. There is new furniture in a lot of the bedrooms and the bedside lockers have a lockable drawer. One bathroom has been converted to a “walk-in” shower and another bathroom was being converted to a shower room. The assisted bathroom was in need of attention, staff it was going to be refurbished. The décor and furnishings were satisfactory and staff said that a lot of redecorating had been done recently. There is very little outside space that can be used by residents, the main area at the back of the home is tarmac and has a fairly steep slope. CCTV is used inside the home to monitor the main entrance and the entrance to the lift and the entrance from the stairs to the landing on all floors. The owners said this had been installed for security reasons. We are concerned about this because of the implications for residents’ privacy and we will be discussing this with the owner when we meet to talk about registration. A new lift was installed in June 2006 and a mobile hoist has been provided. The owner was arranging for this to be serviced and for the hoist in the assisted bathroom to be repaired or replaced. Door locks are fitted to all bedroom doors and staff said one resident sometimes had a key to his room. The locks that are fitted are not single action locks and therefore could be difficult for people with dementia to manage. Residents’ bedrooms were comfortable and suitably equipped. The home felt cool during the visit, one resident was wearing several cardigans and said she felt “chilly”. The owner said thermostatic valves are fitted to control hot water temperatures. The water temperatures are not checked and recorded; this should be done to make sure that the valves are working effectively. To reduce the risk of scalding bath thermometers should be provided in communal bathrooms so that the water temperature can be checked before residents get into the bath. Checks on the hot water system to reduce the risk of Legionella have not yet been done; the owner said he was getting quotes for this. Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 20 There are soap dispensers and paper towels in bedrooms and communal bathrooms and toilets so that staff can wash their hands. The home has a mechanical sluice but it was evident that this is not used. The laundry has a commercial washing machine with a sluice cycle, which is adequate to meet residents’ needs. The home had a Health and Safety inspection in early January 2007 and the owner said no recommendations were made. Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 21 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): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. At the time of the visit there were enough staff to meet residents’ needs. Staffing levels will have to be kept under review to take account of increasing occupancy and residents’ changing needs. Staff are supported in developing the skills and knowledge they need to meet residents’ needs. Recruitment procedures must be followed consistently for the protection of residents. EVIDENCE: Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 22 At the time of the visit there were 7 people living in the home and one person attending for day care twice a week. There are two staff on duty, day and night, one nurse and one care assistant. In addition, during the morning there is a cook and a laundry/domestic assistant. Staffing levels will have to be increased as more people move in; we will be asking the owner for information about how this will be managed. Duty rotas are available for all grades of staff; they should show the full name of each staff member. The home has 8 care assistants and 6 of them are qualified to NVQ (National Vocational Qualification) level 2, this equates to 75 of the care staff team. This exceeds the recommendations of the National Minimum Standards. Another care assistant is doing NVQ level 2 in care and the cook is doing an NVQ in catering. No new staff have been employed since the last inspection. I looked at two staff files, one contained all the required information, the other did not. There was no application form, no references, a CRB (Criminal Records Bureau) check had not been completed before the person started work and there was no evidence that a POVA (Protection of Vulnerable Adults) check had been done before employment commenced. The manager had audited the staff files and identified that these documents were missing. The staff member had been on work placement at the home before she transferred onto the permanent staff, none the less the home is required to make sure that all the preemployment checks have been completed before they allow new staff to start work. The records showed that a lot of training has taken place since the last inspection and care staff confirmed this. The topics covered include dementia awareness, dementia and challenging behaviour, care of people with epilepsy, health & safety, moving and handling, principles of care, infection control, exercise and activity and moving & handling. The manager is planning to introduce the Skills for Care induction standards, which will mean that all new care staff receive detailed induction training that meets national standards. Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 23 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, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been improvements since the last inspection. However, there is still a lot to do and to make sure that the manager has the knowledge and skills to continue the improvement and development of the service it is essential that she undertake the relevant management training. EVIDENCE: The manager is a nurse. She has not completed the required management training, however she is booked on a course, which is due to start in April 2007. The manager works 25 hours a week and is supernumerary. Staff said the owner visits the home most days and that both the manager and owner are contactable by phone when they are not in the home. Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 24 Questionnaires have been sent to residents and relatives asking for their views of the service. There was evidence that residents and/or their representatives had been consulted as part of the care review process. However none of this information was collated or analysed. The home must do more work on developing the quality assurance systems so that they can show how they are taking account of the views of people who use the service. At the last inspection there were some concerns about the systems for dealing with residents’ personal money. This was referred to the Adult Protection coordinator and has been dealt with. The home is still collecting money on behalf of one person; they have referred this to Bradford Social Services and are waiting for them to nominate an appointee. The manager said the home would not get involved in managing money on behalf of any new residents entering the home. A system of staff supervision has been started; this needs to be maintained so that staff have supervision every 2 months. The maintenance records showed that the annual gas safety check has been done and an electrical wiring certificate has been obtained. Weekly checks on the fire alarm system are done but it wasn’t clear how often the emergency lights are checked. Training for staff on fire safety was overdue, it was last done in June 2006, it should be updated every 6 months. Risk assessments were in place for the use of bed safety rails, staff said they do visual checks on them; regular maintenance checks should be done and recorded. Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 25 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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 3 X 2 2 2 STAFFING Standard No Score 27 2 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001, and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 & 12(4) Requirement The Statement of Purpose must be updated to include all the required information. In order for the home to fulfil its stated objective of providing a diverse and multi cultural service the Statement of Purpose and Service User Guide must be made available in alternative languages and/or formats. There must be a photograph of every resident. The registered persons must continue to develop the care plans so that they set out in detail how the personal, health, and social care needs of residents will be met. The registered persons must make suitable arrangements for the safe disposal of unused medicines. Previous timescale of 30/06/06 not met. The medicines trolley must be secured to the wall in the dining Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 27 Timescale for action 30/04/07 2 3 OP7 OP7 17 Sch. 3 15 30/04/07 30/04/07 4 OP9 13(2) 30/04/07 room. The registered persons must make suitable arrangements for providing medicines to residents who are going out for days or weekends. The registered person must review the practice of using CCTV inside the home. If this is to continue it must be made clear in the Statement of Purpose and discussed with prospective residents before admission. In additions polices and procedures must be put in place specifically addressing the following; a) how often the use of CCTV will be reviewed and who will be involved in the decision making b) who will have access to the tapes and c) how long the tape will be kept for. To reduce the risk of scalding 30/04/07 bath thermometers must be provided in communal bathrooms. The registered persons must 30/04/07 make sure that hoists and lifts are serviced at six monthly intervals in accordance with LOLER regulations The registered persons must 30/04/07 provide the CSCI with their proposals for increasing the staffing levels to take account of increased occupancy. The proposals must make it clear how the dependency of residents will be taken into account and make specific reference to staffing for day care. DS0000061941.V317380.R03.S.doc Version 5.2 Page 28 5 OP19 12(4) 30/04/07 6 OP21 13(4) 7 OP22 13(4) 8 OP27 18 Britannia Care Home 9 OP29 19 10 OP31 9 The registered persons must 30/04/07 make sure that all the required checks are completed before new staff start work in the home and that the required records are available for inspection. The manager must commence 30/04/07 training to obtain a recognised management qualification. Previous timescale of 31/10/06 not met. The registered persons must establish and maintain and effective quality assurance and quality monitoring system based on seeking the views of service users. Previous timescale of 31/10/06 not met. The programme of staff supervision must be maintained. The registered persons must make sure that all staff have fire safety training at least twice a year. 11 OP33 24 30/04/07 12 13 OP36 OP38 18 23 30/04/07 30/04/07 Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 29 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 OP2 Good Practice Recommendations The room number to be occupied should be specified in the Terms and Conditions of residency. This document should be made available in an alternative language/format. 2 OP9 The prescriptions should be returned to the home to be checked before they are sent to the pharmacy. The disclaimer on the back of prescriptions should be signed by staff in the home, if residents are unable to do so, before prescriptions are sent to the pharmacy. 3 OP25 There should be a policy on the use of covert medication. Random checks should be carried out on hot water temperatures and a record of these checks should be kept. The registered person should make sure the home is maintained at a comfortable temperature. The locks on the bedroom doors should be replaced by single action with single action locks. The full name of each staff member should be shown on the duty rota. All new staff should have induction training that meets the Skills for Care induction standards. 4 5 6 OP24 OP27 OP30 Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 © 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 Britannia Care Home DS0000061941.V317380.R03.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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