Inspection on 08/09/05 for Casa Mia

This inspection was carried out on 8th September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Casa Mia 23/02/09

Casa Mia 23/04/07

Casa Mia 13/06/06

Casa Mia 29/03/06

Casa Mia 23/03/05

Casa Mia 27/07/04

Casa Mia 03/03/04

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Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

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Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOMES FOR OLDER PEOPLE Casa Mia Cleobury Road Far Forest, Nr Kidderminster Worcestershire DY14 9EH Lead Inspector Andrew Spearing-Brown Unannounced 8 September 2005 10:00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Casa Mia Address Cleobury Road, Far Forest, Near Kidderminster, Worcestershire DY14 9EH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01299 266317 Mr Martin James Winfield Mrs Michelle Dawn Winfield Mr Martin James Winfield Care Home 15 Category(ies) of OP Old age (15) registration, with number PD(E) Physical disability over 65 (15) of places Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may also accommodate a maximum of 3 people over 55 with a mental disorder subject to discussion and agreement with the Commission/see report 2. The home may also accommodate a maximum of 3 people over 55 with a learning disability, subject to discussion and agreement with the Commission/see report 3. The home may also accommodate a maximum of 3 people over 65 years of age with demential illness. Date of last inspection 23 March 2005 Brief Description of the Service: This home provides care for up to fifteen older people who may also have a physical disability. Within that number the service can accommodate up to three people over 65 with dementia, up to three people over 55 years with a mental health need, and up to three people over 55 with a learning disability, the overall total being no more than 15. The home is located in a rural area of Far Forest near to Kidderminster. It provides level accommodation throughout the ground floor, and two bedrooms on the first floor. There are outdoor facilities on two levels, comprising of an attractive patio area and a lower garden – which is accessible to all service users via a ramp. The registered providers are Mr Martin Winfield and Mrs Michelle Winfield.Mr Martin Winfield has responsibility for management of the home. Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken by an inspector from the Worcester office of the Commission for Social Care Inspection (CSCI). The visit lasted four and a half hours from mid morning till early afternoon. The previous inspection took place during March 2005. The main focus of this inspection was to assess the progress made in relation to the requirements from the last inspection as well as assess some standards not inspected upon that occasion. On the day of this inspection the registered manager was on duty. Other staff on duty included carers and a cook; all these persons took some part in the inspection process. A small representative number of residents were consulted. Many areas of the home were seen including some bedrooms and communal rooms. The care records of a small sample of residents were seen. Other documents seen included medication records, staff records and some policies and procedures. What the service does well: Casa Mia carry out pre admission assessments to ensure that care needs are able to be met. Potential residents and / or their relatives are able to visit the home prior to their admission. The atmosphere within the home remains jovial. Staff were seen to respect residents privacy and dignity. Suitable activities are provided for residents by staff and outside entertainers. Communal areas such as the lounge and dining room are well decorated and maintained. The grounds are well maintained; work on the outside decking continues to improve this area further. Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Following this inspection the registered manager was sent a letter detailing a number of serious concerns, which required immediate action. A response was returned to the local office of the CSCI prior to the issuing of this report, detailing the actions taken or proposed. These areas will be re assessed as part of a future inspection at Casa Mia. The areas of concern included a number of fire safety matters including the records regarding the weekly testing of the alarm and the recording of visual checks upon the fire extinguishers. A firebreak glass point remained broken; this was noted as part of the previous inspection. Staff recruitment remains a serious concern. The files of recently appointed staff did not contain the necessary documentation and it was evident that full pre employment checks had not taken place leaving residents at potential risk. Although improvement was noted regarding the overall management of medication further improvement is needed to ensure that the standard is fully met. Amendments required to the homes policies and procedures upon adult abuse remain outstanding. Although communal areas remain homely and suitable for purpose the communal bathing and toilet facilities are in need of improvement. The home lacks suitable storage areas. Although documentation is in place to record information required by Environmental Heath in relation to food safety they remain blank and therefore need to be introduced. Improvements are needed in infection control measures. The number of staff on duty at the time of this inspection was insufficient. The registered provider must ensure that the home is suitably staffed at all times. Shortfalls were identified in staff training, whereby the level of staff who have completed mandatory training and professional training such as National Vocational Qualification (NVQ) needs improving. Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 7 A number of additional health and safety shortfalls were identified and in need of attention. 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. Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 , 3 and 5. Standard 6 is not applicable to Casa Mia. Potential residents are able to visit the home prior to their admission and are assessed by the home to ensure that care needs can be met. The assessment ensures that residents’ needs are effectively and safely meet, improvements are however needed regarding the service users guide and other information available to potential residents. EVIDENCE: The home’s Service Users Guide covered the majority of the areas required and only needs a relatively small number of amendments. However the Statement of Purpose requires major amendments in order to bring it in line with the required standard. A pre admission assessment was viewed for a resident who was admitted into the home a few months ago. The initial assessment contained basic information however it was sufficient in its detail regarding individual care needs to ensure that an initial care plan could be implemented. This information then needs to be built upon as the care plan develops ensuring that all identified care needs are suitable covered. Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 10 A master copy of the homes terms and conditions was viewed; the same document is used as a contract for privately funded residents. This document covered the areas listed within the relevant standard but its title needs to be reviewed accordingly. Residents and or their relatives on their behalf are able to visit the home prior to admission. A trail period is available before residents make a decision about becoming permanent. Intermediate care is not offered at Casa Mia and the home has no plans to provide such as service. Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 9 Progress has been made with regard to improving care plans to ensure that residents care needs are met. However although improvement in medication management was seen these are not sufficient to fully safeguard residents EVIDENCE: Individual records and care plans are kept for each resident. Records seen were suitably informative, addressing individual identified care needs. An improvement in care planning was noted since the previous inspection. The manager reported that the system of care planning is under continual review to ensure the required standard is worked towards. Since the last inspection some improvement was noted regarding medication systems including administering and recording, however further improvements are necessary. It was noted that although locked the medication trolley was not secured to the wall. The key to the medication trolley was stowed along with other keys within a key safe in the kitchen; this key must be retained on a designated person throughout their shift and then passed on to another designated person. A record of who holds the key should be maintained. The home operates a monitored dosage system (MDS) supplied by a major high Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 12 street pharmacy. As the current months medication charts had only just commenced the previous months MAR (medication administration record) sheets were viewed, these sheets were generally well maintained and appropriately signed by staff. Items such as inhalers did not have the date on which the item was opened recorded upon them. Following the last inspection the registered manager was required to ensure that the section on the MAR sheets to record allergies was completed during this inspection it was discovered during this inspection that in the majority of cases the section was blank, if no allergies are known the sheets must stipulate this fact. At the time of this inspection no controlled medication was in use. The medication policy and associated procedures were not viewed as part of this inspection the registered manager stated that the amendment required following the last inspection has not happened. Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 Activities are provided which are creative and stimulating for residents living in the home. EVIDENCE: A bingo machine seen to be causing great joviality during the previous inspection is still used. A number of items of craftwork undertaken by residents were on display within the lounge. Other information on display indicated that entertainers visit periodically. A saxophone was in the lounge, which had been used to play to residents prior to this inspection. A relaxed atmosphere throughout the home was noted. Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 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 standard(s) 18 The vulnerable adults procedure needs to be reviewed to ensure that it is consistent with local procedures in order to ensure that staff are aware of their individual responsibilities therefore safeguarding residents. EVIDENCE: The registered manager stated that Casa Mia has received no complaints since the last inspection. No complaints have been made direct to the CSCI. Residents consulted expressed satisfaction with the care provided at the home. The complaints procedure was not viewed as part of this inspection. The homes procedures in relation to adult protection were seen during a previous inspection and therefore only briefly viewed during this inspection. Following the previous inspection the registered manager was required to obtain a copy of Worcestershire multi-agency policy and procedure upon adult abuse and to ensure that the policy within the care home is compatible with the Worcestershire document. In addition the registered manager needed to obtain a copy of the Department of Health publication ‘No Secrets’. Obtaining these documents has not taken place; these need to be sought without further delay to ensure compliance with this standard and associated regulations. Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 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 standard(s) 19, 21, 23 and 26 Although the communal lounge and dining room are homely some improvements are needed to ensure that residents have a comfortable place to live. EVIDENCE: There have been no significant changes within the environment since previous inspections undertaken by the Commission for Social Care Inspection. The registered manager has a number of plans for future improvement that need to be discussed further with the Commission. Communal area consists of a large lounge with an adjoining dining room. These areas are suitably maintained and homely in appearance. A small sitting area is also provided for residents who smoke. This inspection took place during a warm period of weather; therefore areas such as lighting and heating were not accessed. It was noted that the home and had no unpleasant odours. Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 16 The lock to a bathroom door on the first floor was missing. The bathroom near the ground floor is in need of refurbishment as it is currently unsuitable and out of use. An officer from the local Environmental Health Department recently visited the home. A number of issues were raised as part of that visit some of which are now resolved such as maintaining fridge temperatures. However although forms and documents exist in line with Hazard Analysis for food safety the documentation remains blank. Casa Mia does not have a passenger lift and has no lifting equipment such as hoists. The home lacks suitable storage areas for equipment such as wheelchairs. The grounds are well maintained. A decking area to the rear of the home, which is not yet complete, provides an attractive area for residents to sit. Infection control measures are in need of improvement. No liquid soap dispensers are provided in communal toilets; some paper towel dispensers were in place however all those checked were empty. Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 29 An insufficient number of staff were on duty and recruitment procedures were also found to remain insufficient both of these could potentially place residents at risk. EVIDENCE: The rota for the current week was seen as part of the inspection. This was not an accurate reflection of the staff on duty during the inspection. The rota indicated that two carers were on duty on the morning of this inspection. However it was necessary for a carer to remain on duty after she had finished her shift, as one carer was required to go out as an escort with a resident. This should have been planned in advance and covered appropriately. Other than the manager the only other person in the home was cooking lunch. The registered manager must ensure that adequate staff are on duty at all times to meet the care needs of residents The staff files for two newer members of staff were viewed these indicated that the necessary recruitment checks to ensure the protection of residents had not taken place. One file contained an application form however it was not completed fully. The other file contained no application form at all. No references were held within either of the two files viewed. One file contained a suitable CRB (Criminal Records Bureau) check regarding the individual employee. The other file however only contained the original CRB check application form; although this was completed it was in excess of 1 month since the person had commenced work at Casa Mia, no POVA first (Protection Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 18 of Vulnerable Adults) check had been sought by the home. As a result of the serious shortfalls an immediate notice was issued. One member of care staff currently holds an NVQ (National Vocational Qualification) level 3 qualification while another has achieved a level 2 qualification. Although another member of staff is starting her level 3 award the current percentage of qualified staff equates to 25 whereas the National Minimum Standard state that 50 of qualified staff should be obtained prior to 31st December 2005. Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38 Shortfalls regarding fire safety and some other health and safety matters potentially left residents at risk. EVIDENCE: The registered manager is shortly due to commence upon both the Registered Managers Award and the NVQ (National Vocational Qualification) level 4 in management. A number of serious shortfalls were noted in relation to fire safety and documentation. Some of the shortfalls were noted as part of the previous inspection including a break glass point in the lounge, which needed to be repaired. Despite the assurance that this matter was in hand the situation remained the same. On arriving at the home it was noted that a considerable number of fire doors were wedged open. Although the number reduced before a tour of the building a significant number remained in that state. These doors included both entrances to the kitchen; one of these doors was held open by Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 20 using a sack of vegetables. In addition a corridor door and bedroom doors were open, a wedge was noted on the floor in an upstairs bedroom. The smokers lounge door was held open by means of a footrest from a wheelchair. The fire log indicated that the weekly testing of the alarm does not including all break glass points around the home furthermore it also indicated that the monthly visual checking of the fire fighting equipment is either not taking place or no recording is taking place of the check. It was noted that the annual inspection of fire fighting equipment last took place on 21/07/04, therefore over due by seven weeks. Fire training needs to be arranged as a matter of urgency as the last training took place during August 2004 therefore over 12 months ago. As a result of the above matters regarding fire safety an immediate improvement notice was issued at the end of the visit. It remains unclear whether some chairs within residents bedrooms meet The Furniture and Furnishing (Fire) (Safety) Regulations 1988 (as amended 1989 and 1993). No audit has taken place to determine the ownership of these items and no suitable risk assessments are in place. Shortfalls were noted in relation to some mandatory training. Moving and handling is due to take place in the foreseeable future. The registered manager stated that having 4 qualified first aiders would ensure that one is always on duty. The accident records were viewed; these are recorded within a book no longer permitted, due to the Data Protection Act 1998. The registered provider needs to ensure that a suitable audit of accidents takes place. It was noted that wheelchairs within the smokers lounge were without footrests. The removing of these can be potentially dangerous in the event of wheelchair usage without them in place. The large pond on the decking area remains uncovered. This is particularly hazardous as seating is provided whereby residents are able to sit with their back to the pond. Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 x 2 x 3 x x 2 STAFFING Standard No Score 27 2 28 2 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 2 x x x x x x 1 Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 (1) Requirement The registered provider must ensure that a Statement of Purpose is prepared which includes all the information detailed in Regulation 4 and Schedule 1. Timescale for action 30/10/05 2. 1 5 (1) 30/10/05 The registered provider must ensure that the Service User’s Guide is ammended to include all the information detailed in Regulation 5 and Standard 1. It must be available in the home and copies must be given to all current, and any prospective, service users. The registered provider must immediate ensure that service users’ drug and on records show known allergies. going When none are known the record must state ‘None known’. (Previous timescale of immediate and on going not met - action must be immediate) 3. 9 13 (2) Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 23 4. 9 13 (2) The registered provider must ensure that policies and procedures relating to medication are reviewed. (Previous timescale of 31/05/05 not met - the timescale is extended.) 30/10/05 5. 9 13 (2) The registered provider must ensure that medication is suitably secured. This includes the medication trolley chained to the wall and the safekeeping of the keys upon a nominated person. The registered provider must ensure that adult protection policies and procedures are in line with Department of Health guidance and local procedures. (Previous timescale of 31/05/05 not met - the timescale is extended) immediate and on going 6. 18 13 (6) 30/10/05 7. 19 23 (5) The registered provider must ensure that the requirements made by the local authority Environmental Health Officer are met, included the need to introduce a hazard analyse. 21/10/05 8. 19 21 23 (2) (b) The registered provider must 31/12/05 ensure that all areas of the home, including bathrooms and toilets are well maintained and in good and sound order. (Previous timescale of 31/08/05 not met - the timescale extended) Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 24 9. 26 13 (3) The registered provider must ensure that suitable arrangements are in place to prevent the risk of cross infection including the provision of hand washing facilities. (Previous timescale of 31/05/05 not met - the time scale is extended) 30/10/05 10. 27 18 (1) (a) The registered provider must ensure that sufficant numbers of staff are on duty at all times to meet the care needs of residents. The registered provider must operate a thorough recruitment system in accordance with the requirements of this regulation and Schedule 2 of the Care Homes Regulations 2001. Disclosure checks from the Criminal Records Bureau must be obtained for all new staff before their appointments are confirmed. (Previous timescale of immediate and on going not met immediate action must be taken) Immediate and on going 11. 29 19 Immediate and on going 12. 38 23 (4) The registered provider must ensure that all soft furniture such as chairs provided by the home meet The Furniture and Furnishing (Fire) (Safety) Regulations 1988 (as amended in 1989 and 1993). (Previous timescale of 31/07/05 not met - timescale is extended) 31/12/05 Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 25 13. 38 23 The registered provider must ensure that fire break glass points are maintained as required and that all fire break glass points are tested weekly and sequentially. (Previous timescale of immediate and on going not met immediate action must be taken) Immediate and on going 14. 38 23 The registered provider must make suitable arrangements to ensure that fire doors do not have to be propped open to afford service users ease of passage The registered provider must ensure that fire fighting equipment undergoes an annual inspection and monthly visual checks. All of these must be recorded. The registered provider must ensure that all staff have received mandatory training including fire awareness and moving and handling. The registered provider must ensure that the accident book conforms to Data Protection Requirements. Immediate and on going 15. 38 23 Immediate and on going 16. 38 13 23 31/11/05 17. 38 13 30/10/5 18. 38 13 The registered manager must Immediate ensure that the health safety and and on welfare of service users is going protected at all times by means of ensuring suitable risk assessments are carried out. In particular attention must be given to the pond and decking areas. (Previous timescale of immediate and on going not met immediate action must be taken) E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 26 Casa Mia 19. 38 13 The registered provider must ensure that footrests on wheelchairs remain in place and are not removed. immediate and on going 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. Refer to Standard 2 28 Good Practice Recommendations The registered provider should review the homes terms and conditions. The registered provider should have an action plan as to how the 50 of carers qualified to NVQ level II standard will be achieved. (The recommedation was made within the last inspection report. As 50 of carers need to be qualified by 31/12/05 in order to meet this standard it is strongly recommended that a plan as to how this is going to be achieved is devised) Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 27 Commission for Social Care Inspection The Coach House, John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Casa Mia E52 S18499 Casa Mia V247410 080905.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!