Inspection on 12/01/05 for Butler Green House

Care Home For Older PeopleButler Green HouseWallis Street Chadderton Oldham OL9 8NGAnnounced Inspection12th January 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Butler Green House Address Wallis Street, Chadderton, Oldham, OL9 8NG Email address socs.gwylfa.evans.@oldham.gov.uk Name of registered provider(s)/company (if applicable) Oldham M.B.C. Name of registered manager (if applicable) Teresa Lever Type of registration Care Home No. of places registered (if applicable) 39 Tel No: 0161 911 5086 Fax No:Category(ies) of registration, with (number of places) Dementia - over 65 years of age (10), Old age, not falling within any other category (28), Physical disability over 65 years of age (18) Registration number F040000346 Date first registered Date of latest registration certificate 22nd December 2003 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 19th July 2004 NO YES 11/08/04 If Yes refer to Part CButler Green HousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 312th January 2005 09:30 am Carol MakinID Code074703Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionTeresa LeverButler Green HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementButler Green HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Butler Green House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Butler Green HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Butler Green House is a purpose built establishment, commissioned and managed by Oldham Metropolitan Borough Council. Designed around a central hub, the ground floor is home to 39 people who are elderly and have physical disabilities. There are three distinct units, each one having a kitchen, lounge, dining area and bedrooms. One unit is designated for service users who require intermediate care. All bedrooms are single occupancy and are above the minimum space standards. There are no en-suite facilities. All the bedrooms are lockable and there is a secure facility within each room. There are aids and adaptations to meet the assessed needs of the service users. The gardens are well maintained and provide seating for the service users in the better weather. The home is located in a residential area of Chadderton with access to local and community resources.Butler Green HousePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This announced inspection took place on 12th January 2005. It was found that many of the assessed standards had been met or partially met, and service users who chose to speak with the inspector expressed satisfaction with the care they were receiving. Comment cards were sent to 12 service users, 3 visiting health professionals and 2 social workers. At the time of writing this report, 8 comments cards had been returned to the Commission for Social Care Inspection by service users, all of whom responded positively regarding the service provided at Butler Green House. Choice of Home (Standards 1-6) A statement of purpose and a service users guide were available for inspection, but required further work to meet fully with the standard. A statement of terms and conditions was available on the files inspected as required. Health and Personal Care (Standards 7-11) Care plans and risk assessments were in place, and regular reviews of care needs were carried out. There was documentary evidence to show that service users or their representative had been involved in completing the care plan. A general practitioner and a physiotherapist, who spoke with the inspector during the inspection, were very complimentary about the standard of care provided by the management and staff at the home. Daily Life and Social Activities (Standards 12-15) The above standards were not fully assessed on this occasion, but service users who spoke with the inspector felt that the daily routine in the home was flexible, and they were very positive in there comments about the meals provided. Complaints and Protection (Standards 16-18) A complaints procedure was in place. All service users are entered onto the electoral register on admission and voting can take place either in person or by postal vote. Environment (Standards 19-26) The accommodation is purpose built. The grounds are fully accessible to the service users. At the time of the inspection the home was found to be clean and free from unpleasant odours.Butler Green HousePage 6 Communal areas presented as being attractively furnished and decorated. There are several small lounge areas and a large open plan sitting area to the front of the building. All bedrooms are single occupancy. Those which were viewed during the inspection, were personalised, and furnished and decorated to a good standard. There are no en-suite facilities. Staffing (Standards 27-30) Staffing rotas provided for inspection indicated that there were sufficient numbers of staff on duty at that time to meet the standards set by the former regulating authority. Requirements have been made regarding staff records, and NVQ training. Management and Administration (Standards 31-38) Since the last inspection the managers registration has been approved. Her qualifications include HNC in Social Care Management, and she is an NVQ Assessor. Some records required by regulation are not held within the home. Requirements and recommendations have been made regarding some health and safety issues.Butler Green HousePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Butler Green HousePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The registered person must ensure that statement of purpose and service user guide are provided in accordance with the Regulations and the National Minimum Standards. (Timescale of 1/11/04 not met). 2 17(1)(a) OP9 The registered person must ensure that an accurate individual record is made of the administration of each medication. The registered person must ensure that a minimum ratio of 50 trained staff (NVQ 2 or equivalent) is achieved by April 2005. The registered person must ensure that records are maintained in accordance with Schedules 2 and 4 of the Care Home Regulations 2001 and are available in the home for inspection. The registered person must ensure there is a system of quality assurance and quality monitoring in place, in accordance with the standard and the regulations. (Timescale of 1/11/04 not met). Immediate14&5OP131/03/05318OP2830/04/05417(2) & 19OP2931/03/05524OP3331/03/05Butler Green HousePage 9 STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 6 16 OP38 The registered person must ensure that the kitchen is properly ventilated at all times. (Timescale of 1/11/04 not met). 7 23 OP38 The registered person must ensure that tests and checks in relation to fire precautions are Immediate carried out and recorded at the prescribed intervals. 31/03/05Butler Green HousePage 10 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 3 OP21 OP38 OP38 The registered person should ensure that sluices are located separately from service users toilet and bathing facilities. The registered person should ensure that the food storage area, which is situated near to the kitchen toilet facility, is enclosed. The registered person should ensure that all tests and checks in relation to fire precautions are recorded in the same book. The registered manager must demonstrate to the Commission for Social Care Inspection, that her qualifications are equivalent to an NVQ 4 Care and Management qualification.4OP31* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Butler Green HousePage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES NO NO NA YES YES YES NO YES YES YES NO YES YES YES YES 6 4 0 NO NO YES YES 26 0 12/1/05 9.25 8.25Butler Green HousePage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Butler Green HousePage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) 327.00Any charges for extras If yes, please state what the extras are:YESNEWSPAPERS, HAIRDRESSING, TOILETRIES. 2 Key findings/Evidence Standard met? The registered manager stated that Social Services Finance Department had informed her that fees are means tested, and are assessed to a maximum amount as shown in the table above, with no set lowest fee. The statement of purpose and the service user guide were available for inspection. Further amendments were required for these documents to fully comply with the regulations and the standards. The Registered Person must ensure that statement of purpose and service user guide are provided in accordance with the Regulations and the National Minimum Standards.Butler Green HousePage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? There evidence available on the service users files viewed during the inspection to indicate that this standard had been met.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Butler Green HousePage 15 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Butler Green HousePage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? A requirement regarding this standard, which made as a result of the last inspection had been addressed, and the standard was met on this occasion.Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence This standard was not assessed on this occasion. X X Standard met? 0Butler Green HousePage 17 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? The medication records for service users which were selected for were found to be in order with the following exception: Medication had been removed from the blister pack but the record sheet had not been signed by staff to confirm that the tablets had been administered to the service user. The registered person must ensure that an accurate individual record is made of the administration of each medication. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? Information obtained during discussions with service users, the manager and staff, and observations of practice and facilities during the inspection, indicated that this standard was met.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? It was reported that service users could remain at Butler Green House, whilst their needs were able to be met in conjunction with the district nursing service. Policies and procedures concerning the management of death and dying were in place.Butler Green HousePage 18 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Butler Green HousePage 19 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Butler Green HousePage 20 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 X 3 Key findings/Evidence Standard met? The registered person provided the above information, in the pre - inspection questionnaire, which was returned to the Commission for Social Care Inspection. A complaints procedure was available in the statement of purpose.Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? All service users are entered onto the electoral register on admission. They are enabled to exercise their right to vote either in person or by post.Butler Green HousePage 21 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence This standard was not assessed on this occasion. Standard met? X X 0Butler Green HousePage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home is purpose built accommodation. It was reported that the grounds/gardens are maintained by Oldham Council, and minor works/repairs are contracted out to private companies. Automatic closure devices had been fitted to office doors, which the registered manager reported was in accordance with a requirement made following an inspection of the premises by Greater Manchester Fire Service. There was evidence that a programme of renewal of the fabric and decoration of the premises was in progress, which included some new lounge carpets, window blinds, redecoration and renewal of bedroom furniture, and the purchase of new large screen televisions.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? This standard was not fully assessed on this occasion, but the requirement for a new carpet to be fitted in green wing, made following the last inspection, had been addressed.Butler Green HousePage 23 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 2 Key findings/Evidence Standard met? The registered manager reported that in response to a recommendation for sluices to be located separately from service users toilet and bathing facilities made following the last inspection, officers from the local authority, had assessed the matter and were considering ways of addressing it. The registered person should ensure that sluices are located separately from service users toilet and bathing facilities. Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not fully assessed on this occasion, but the requirement for storage facilities for aids and equipment, made following the last inspection, had been addressed.Butler Green HousePage 24 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO NO 39 0 0 0 39 03 0 0 03 Key findings/Evidence Standard met? It was reported that all the bedrooms are 13 square metres and, as such, fully meet the standard.Butler Green HousePage 25 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? This standard was not fully assessed on this occasion.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? This standard was not fully assessed on this occasion.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? This standard was not fully assessed on this occasion, but the home was found to be clean and free from unpleasant odours at the time of the inspection.Butler Green HousePage 26 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X 0 needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X 0 0 0X X X0 Key findings/Evidence Standard met? This standard was not fully assessed on this occasion, but rotas for the week of the inspection were checked against the standards of the former registering authority, and staffing levels within the home met those standards.Butler Green HousePage 27 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 4 14 2 Key findings/Evidence Standard met? The registered person provided the above information, in the pre - inspection questionnaire, which was returned to the Commission for Social Care Inspection. It was reported that 7 members of staff were undertaking NVQ training at the time of the inspection. The registered person must ensure that a minimum ratio of 50 trained staff (NVQ 2 or equivalent) is achieved by April 2005.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? It was reported that personnel files for staff continue to be held at the head office of the Social Services Department. Basic information regarding staff was available in the home, together with their training/ development file. The registered person must ensure that records are maintained in accordance with Schedules 2 and 4 of the Care Home Regulations 2001 and are available in the home for inspection. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Butler Green HousePage 28 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? Since the last inspection the managers registration has been approved. Her qualifications include HNC in Social Care Management, and she is an NVQ Assessor. The registered manager should demonstrate to the Commission for Social Care Inspection, that her qualifications are equivalent to an NVQ 4 Care and Management qualification.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Butler Green HousePage 29 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? Discussions with the registered manager indicated that progress had been made regarding the provision of a quality assurance and quality monitoring system, but further work was required to meet the standard. The registered person must ensure there is a system of quality assurance and quality monitoring in place, in accordance with the standard and the regulations. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 2 Key findings/Evidence Standard met? A current certificate of insurance cover was displayed in the home. The registered manager reported that as on previous inspections, a business and financial plan for the establishment were not available in the home for inspection. The following requirement, which was made as a result of previous inspections, remained outstanding. The registered person must ensure that a financial plan and a business plan and records of transactions in relation to the running of the home are available for inspection.Butler Green HousePage 30 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence This standard was not assessed on this occasion. Standard met? 0 X X XStandard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? There was evidence that a system of staff supervision and appraisal had been implemented in line with this standard.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? This standard was not fully assessed on this occasion, but as stated when reporting on compliance with standard 29, the majority of staff records required by regulation were not available in the home for inspection.Butler Green HousePage 31 Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? The following requirement and recommendation, made as a result of following the last inspection, remained outstanding, although the registered manager reported that officers from the local authority, had assessed the matters and were considering ways of addressing them: The registered person must ensure that the kitchen is properly ventilated at all times. The registered person should ensure that the food storage area, which is situated near to the kitchen toilet facility is enclosed. An examination of the fire precautions records identified the following shortfalls, the majority of which were outstanding from the last inspection: A specific record was needed regarding weekly inspections of the means of escape from fire. Fire extinguishers needed to be checked by a nominated person in the home once per month to ensure that access to them is not obstructed and they are readily available for use. The fire alarm must be tested and recorded at weekly intervals. Various recording systems for recording tests and checks in relation to fire precautions were in use at the time of the inspection. It was recommended that all tests and checks in relation to fire precautions should be recorded in one book. The registered person must ensure that tests and checks in relation to fire precautions are carried out and recorded at the prescribed intervals. The Registered Person should ensure that all tests and checks in relation to fire precautions are recorded in the same book.Butler Green HousePage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorCarol MakinSignature Signature SignatureRegulation Manager Keith Lowe DateButler Green HousePage 33 Public reports It should be noted that all CSCI inspection reports are public documents.Butler Green HousePage 34 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on enter date(s) of inspection here and any factual inaccuracies: Please limit your comments to one side of A4 if possibleButler Green HousePage 35 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 21/02/05, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YES D.2Action plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Butler Green HousePage 36 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Butler Green HousePage 37 Butler Green House / 12th January 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000035532.V143533.R01© This report may only be used in its entirety. 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