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Inspection on 16/05/06 for Cole Valley Nursing Home

Also see our care home review for Cole Valley Nursing Home for more information

This inspection was carried out on 16th May 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The standard of accommodation is good and provides a clean and homely atmosphere. Two thirds of the requirements from the last inspection have been addressed. The home has a comprehensive system for the safe administration of medications. Positive comments were received from some residents, such as, "They treat you properly, staff are very friendly". Further remarks received from relatives included, Home is excellent, haven`t had a penny worth of problems, staff are so good and friendly". Visitors are invited to make hot drinks for themselves. Bedrooms are decorated when they become vacant or when needed.

What has improved since the last inspection?

The registered manager carries out a falls audit, which has resulted in a reduction in the number of falls of residents. The amount of activities offered to residents has recently increased. A laminated label now identifies individual`s wheelchairs.Currently the maintenance operative is shared with the sister home, this is due to change with the employment of part time dedicated maintenance operative for the home. A number of specialist mattresses have been purchased; most beds now include pressure relieving mattresses. A profiling bed has been purchased. The specialist mattress has a thin mattress beneath it to ensure that the safety rails remain fully functional. A shared room has been converted to a spacious single room with en0suite facilities. The arrangements for staff recruitment have improved and are now satisfactory.

What the care home could do better:

Staff must ensure that all courses of each meal are served at the appropriate temperature. Risk assessments must include detailed instructions for staff to action to ensure that the identified risk is minimised as far as practically possible. The current system for the recording the descriptions of wounds is not adequate. Documentation within care plans needs to improve in various aspects and formal reviews carried out with the resident and relatives being invited to participate. The induction programme for care staff must reflect the contents of Skills for Care and the gaps in staff training need to be addressed. All staff that provide personal care must have formal supervisory meetings at least six times per year.

CARE HOMES FOR OLDER PEOPLE Cole Valley Nursing Home 326 Haunch Lane Kings Heath Birmingham West Midlands B13 0PN Lead Inspector Kath Strong Unannounced Inspection 16th May 2006 09:45 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 Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cole Valley Nursing Home Address 326 Haunch Lane Kings Heath Birmingham West Midlands B13 0PN 0121 444 8887 0121 441 1959 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) Cole Valley Care Limited Michele Laraine Clarkson Care Home 45 Category(ies) of Dementia - over 65 years of age (45), Old age, registration, with number not falling within any other category (45) of places Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 45 males and females over the age of 50 years for general nursing care That the registered manager completes the Registered Managers Award by August 2006. 19th December 2005 Date of last inspection Brief Description of the Service: Cole Valley Nursing Home is purpose built on two levels, with a passenger lift for access to the first-floor. Occupancy is for up to 45 residents of 65 years or above who may be suffering from dementia, a variation of registration permits the home to accept persons who are aged 50 years or above. The Home is located within the Kings Heath district of Birmingham, and is situated in a residential neighbourhood close to local amenities including shops and public transport. The Home is pleasantly furnished and decorated and aims to offer a warm, homely environment for elderly people requiring nursing care. There is a small car park adjacent to the Home and sheltered, private gardens for service users and their visitors to frequent. Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over a period of one day and the registered manager provided assistance throughout. A shared room has been converted to a single; therefore the home currently accepts a maximum of 44 persons. At the time of the inspection there were 41 residents. All of the key standards were assessed, the requirements generated from the last inspection were reviewed for progress achieved and relevant documentation was examined. Five care plans were assessed, one of which was case tracked in order to determine if all identified needs were being met. Six residents were spoken with individually as well as the relatives of four residents. Two staff interviews were carried out, staff files explored and a tour of the premises was conducted. At the conclusion verbal feedback was supplied to the registered manager. What the service does well: What has improved since the last inspection? The registered manager carries out a falls audit, which has resulted in a reduction in the number of falls of residents. The amount of activities offered to residents has recently increased. A laminated label now identifies individual’s wheelchairs. Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 6 Currently the maintenance operative is shared with the sister home, this is due to change with the employment of part time dedicated maintenance operative for the home. A number of specialist mattresses have been purchased; most beds now include pressure relieving mattresses. A profiling bed has been purchased. The specialist mattress has a thin mattress beneath it to ensure that the safety rails remain fully functional. A shared room has been converted to a spacious single room with en0suite facilities. The arrangements for staff recruitment have improved and are now satisfactory. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 The quality outcome in this area is adequate. Prospective residents and external professionals are not supplied with sufficient written information to enable them to make an informed decision about the home. Comprehensive pre-admission assessments are carried out before a placement is offered. EVIDENCE: The statement of purpose and service user guide were examined and found to need further development. Statement of purpose: • The home is advised to include details of numbers and designation of staff on duty at each shift • The section regarding registration does not include information about the variation for the home to admit persons aged 50 years and above. The service user guide: • Indicates that the last meal of the day is served during the early evening and fails to inform that supper is provided at 8pm. Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 9 • Contracts of terms of residency issued to residents need to include details of the bedroom occupied and details of any services that are not included in the basic fee rate. The registered manager advised that pre-admission assessments are carried out either by herself or a senior nurse at a location convenient to the resident. Examination of the tool used and details recorded indicated that sufficient information is obtained to determine if the home is able to meet all of the identified needs. Further information may be added between the assessment and admission date. Visits to the home are encouraged and the prospective resident is invited to spend a day at the home before making a decision. Following admission a trial period of one month is agreed. Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The quality outcome in this area is adequate. The health care needs and involvement of external professionals are good but not reflected in the standard of the care planning. The arrangements for the administration of medications are satisfactory in preventing residents from incidents of harm. Staff practices ensure that the privacy and dignity of residents are maintained. EVIDENCE: A food diary is maintained for any residents where nutritional concerns are identified and the advice of a GP and/or a dietician is readily sought. Other professionals are consulted when needs are identified such and Speech and Language Specialists and Psychogeriatricians. Where necessary the home has further assessments carried out when concerns are identified regarding the homes ability to meet all of an individuals needs. A free chiropody service is provided twice a year and some residents have more regular input on a private basis. The registered manager informed that some difficulties are being encountered in securing the services of dentists and that the Primary Care Trust had been consulted about this. This good practice is not cascaded into the care planning process, a number of concerns were found: Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 11 • • • • • • • • • • No dedicated recording tool for the input of all external professionals making it difficult to track complications and extra needs. The tool needs to include the rationale and outcome of visits made A risk assessment in respect of absconding does not include the action to be taken by staff to minimise the risk Written descriptions of wounds are not satisfactory. There should be regular recordings of the size, grade, appearance, odour and monitoring. Records should be made in one section only of the care plan No evidence of formal reviews with the resident and relatives being invited to participate Care plans need to include life history, background and preferences. This is especially important for those residents suffering from mental health illness One file indicated that six care plans had been devised but only four could be found The content varies with some being comprehensive and others too brief resulting in a fragmented system There were some gaps in the recording of monthly weights Care planning for those who display difficult to manage behaviour need to include likely triggers, a description of the probable behaviour pattern and instructions for staff in how the respond No short-term care plans were found for complications such as chest or urinary tract infections. Residents and relatives reported their satisfaction with the standards of care. One resident said, “No complaints, I enjoy living at the home”. Relatives reported, “Home is excellent, staff will phone to give details if problems occur”. The process for the ordering, receipt, storage, administration, documentation and disposal of medications was checked and found to be satisfactory. The home has recently reviewed the written procedure to include the changed method for the disposal of unused medications. From observations and discussions with residents and relatives no concerns were noted regarding staff practices in ensuring that residents dignity is preserved. Staff were seen using the preferred term of address. Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality outcome in this area is adequate. Varied activities are provided to stimulate and enhance the quality of resident’s lives. Residents and relatives are consulted and are able to influence the day to day running of the home. The meals are good offering both choice and variety and special diets are catered for. EVIDENCE: The in-house activities offered to residents have recently been improved in respect of variation. The homes continued inability to recruit an activities organiser, lack of documentation in respect of life history, preferences and aspirations and lack of a dedicated tool to record those who have participated fails to ensure that adequate arrangements are in place. External entertainers visit the home and one resident regularly goes out to a luncheon club. There is no formal activities programme, the registered manager advised that residents are more likely to participate on an ad hoc basis. Advice was given that the situation should be reviewed regularly in order to confirm that this is still the most efficient method. Due to the nature of the illness of the majority of residents the home does not have regular residents meetings. The registered manager said that previous attempts have resulted in no-one attending. She also said that an attempt to hold regular surgeries also resulted in no interest being shown. Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 13 It was evident during the inspection that the registered manager operates an open door approach; relatives spoken with confirmed this. Two weeks of current menus were supplied with the pre-inspection questionaire; they indicate a varied and balanced diet with ample choices. The service user guide indicates that the last meal of the day is served at 6pm. The registered manager advised that sandwiches and snacks are available at any time between supper and serving of breakfast at 8.30am. It is recommended that the service user guide and menus are further developed to reflect this. The menu indicates that a full cooked breakfast can be requested on any morning. The main meal is served at lunchtime and gives two choices for main courses and that omelettes can be requested, the dessert consists of two choices as well as yoghurts and ice cream. Soup is available as well as a light cooked meal, sandwiches and a dessert for the evening meal. It was evident on the day that the home caters for specialist diets, also Asian and vegetarian diets. Lunch was observed being served, the meal was well presented and staff were seen being courteous and helpful. Some residents had their meal in their bedroom, staff were observed taking two hot courses to the rooms. The registered manager was advised that staff must ensure that meals are served at appropriate temperatures by serving individual courses to resident’s bedrooms. Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality outcome in this area is adequate. Resident’s comments are listened to and any concerns raised are investigated appropriately. There are good arrangements in place to protect residents from abuse but some staff have not received training in this aspect of care. EVIDENCE: The home has a written complaints procedure, which was found to be satisfactory. Two complaints have been received since the last inspection, one was dealt with by the home and the other investigated by CSCI. The latter complaint was partially upheld in respect of a fall however; as a consequence the home has improved its practices. The home uses the Birmingham City Council guidelines as the tool in respect of adult abuse and there is a separate whistle blowing policy in place. A recent incident in the home confirmed that the home had acted appropriately in responding to the situation. The two staff interviewed provided acceptable responses to questions pertaining to abuse but did not have sufficient knowledge regarding the system. The training matrix supplied shortly prior to the inspection indicated that there are significant gaps in staff training. Further courses need to be arranged in order to capture all staff. Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26 The quality outcome in this area is good. Residents live in a warm, comfortable, well-maintained and safe environment. EVIDENCE: There is a homely atmosphere with a good choice of spacious communal rooms and a secluded garden for residents and visitors to frequent. There are three well appointed lounges and a separate dining room. All rooms are tastefully furnished and offer plenty of scope for socialising events. Bedrooms have en-suite facilities consisting of toilet and wash hand basin and there are communal toilets and assisted bathing facilities strategically located throughout the home. The home appeared to have an adequate supply of specialist equipment and has a call system. The two floors can be accessed via a shaft lift. Bedrooms were comfortable, contained sufficient furniture and were very personalised. Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 16 Residents are encouraged to bring personal possessions and items of furniture into the home. Residents are invited to arrange the furniture to their liking. Rooms included suited door locks; the registered manager advised that some residents held their own keys. The name of the key worker is displayed on the inner side of each bedroom door. The home was noted to be warm, light and airy. Random hot water checks are carried out and recorded for all outlets that residents have access to. Hygiene practices within the kitchen were noted to be satisfactory. The arrangements in the laundry were adequate and each resident had their own baskets for storage of clean clothes. The home was found to be clean throughout and included acceptable odour management. Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality outcome for this area is adequate. The allocated staffing levels are such to provide adequate care for the current client group. Recruitment practices are robust thus ensuring that residents are protected from harm. Staff training is not sufficient to provide staff with the knowledge and skills to carry out their roles. EVIDENCE: Copies of the staff rota were supplied prior to the inspection, which indicated acceptable numbers and skill mix are allocated for day and night shifts. Some gaps are covered by the homes own staff and the remainder by agency staff. Where possible agency staff are supplied who have been to the home previously and therefore have some knowledge of the residents. A sample of five staff files were checked. All relevant checks had been carried out prior to staff commencing employment. Of the care assistants currently employed 56 have successfully completed NVQ level 2 training or equivalent. The home has recently introduced an inhouse induction programme that includes the elements within the Skills for Care programme. A few staff had not completed training in Moving and Handling and Fire Safety however; significant gaps were found for other training. These included Food Hygiene, Elder Abuse, Mental Health, Aggression, Health and Safety and Dementia Care. Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32 33, 35, 36, 38 The quality outcome in this area is adequate. The manager demonstrates leadership qualities and staff have clear lines of accountability. The quality assurance system needs to be further developed. Staff are not receiving formal supervisions in respect of their standards of performance. Health and safety practices are not satisfactory in protecting residents and staff from harm. EVIDENCE: The registered manager is an experienced qualified nurse; she has worked within the care sector for several years and is currently undertaking the Registered Managers Award. During the inspection she demonstrated her ability to manage the home and staff provided positive feedback. She is supported by her line manager whom she meets with regularly and maintains telephone contact with. A senior nurse who is not supernumery also supports the registered manager. Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 19 The home is advised that the senior nurse should have a regular supernumery period allocated in order to hold meetings with the registered manager and assist with the management of the home. The home sends out random questionnaires to residents and relatives and regular audits of the care plans and medication system are carried out. The registered manager was advised that further development needs to take place including a report, which is shared with residents and staff before full compliance will be achieved. The arrangements for the safekeeping and financial transactions of resident’s personal monies was examined and found to be satisfactory. Staff meetings are held at least six times per annum and minutes are on display in the nurse’s office. With the exception of the medication policy written policies and procedures were found to be in need of review. Staff advised that they are not receiving formal supervisory meetings at least six times per year. Documentation for recording of accidents is well maintained and risk assessments of the premises and fire procedures were in place. All checks and required servicing of equipment have been carried out. A member of the care team was observed moving a wheelchair footplate to a safe area in the dining room to prevent the risk of trips; this is viewed as being good practice. As previously discussed the home needs to complete the programme of staff training in respect of Fire Safety and Moving and Handling including refresher courses. Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 20 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 3 3 x 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 x 3 1 x 2 Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 21 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(1) Sch 5(1) Requirement The registered person must further develop the statement of purpose as per Schedule 1. The registered person must further develop the service user guide to include all items listed in Standard 1.2. 2. OP2 5(1)(b) The contract of terms and conditions of residency must be further developed. The registered person must ensure care plans and risk assessments are comprehensive, as outlined within the relevant section of this report. (Previous timescale 19/07/05 not met) The registered person shall ensure the care plans and risk assessments are regularly formally reviewed with residents and relatives being invited to participate. The registered person shall DS0000024835.V294229.R01.S.doc Timescale for action 31/08/06 31/07/06 3. OP7 15(1)(2) (b) 31/07/06 4. OP7 15(1)(2) (b) 31/08/06 5. OP7 15(1)(2) 30/06/06 Version 5.2 Page 22 Cole Valley Nursing Home (b) 6. OP8 17(2) Sch4 (3)n ensure the weights of residents are recorded monthly. The registered person shall ensure the records in place in relation to the incidence of pressure sores clearly reflect the condition and progress of each wound/sore. (Previous timescale of 31/01/06 not met) The registered person shall ensure that residents exercise choice and that the activities programme provided is tailored to meet aspirations. Documentation must include background and life history and a dedicated section regarding individual’s participation. The lack of formal programme must be regularly reviewed. The registered person shall actively recruit an activities organiser. The registered person shall ensure that food is served at appropriate temperatures. The registered person must ensure that all staff receive training in adult abuse. The registered person must ensure that all staff receive training and relevant refresher courses in Moving and Handling, Food Hygiene, Fire Safety, Dementia care, Aggression, Health and Safety and Mental Health. Previous timescale of 18/10/05 The registered manager must achieve a recognised management qualification. The registered person must further develop the quality assurance system and include an annual report, which is shared with residents and staff. DS0000024835.V294229.R01.S.doc 31/07/06 7. OP12 12(1)(a) 12(4)(a) 30/08/06 8. 9. 10. 11. OP12 OP15 OP18 OP30 OP38 16(2)(n) 16(2)(i) 13(6) 18(1)(c) (i) 30/08/06 20/06/06 30/09/06 30/09/06 12. 13. OP31 OP33 9(2)(i) 24(1)(2) (3) 30/11/06 15/10/06 Cole Valley Nursing Home Version 5.2 Page 23 14. OP36 18(2) 15. OP36 17(2) Sch4 The registered manager must ensure that all staff that provide personal care receive at least six recorded supervisory meetings each year. All written policies and procedures must be regularly reviewed and amended as appropriate. 31/07/06 30/09/06 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 OP15 OP31 Good Practice Recommendations The menu and service user guide should include details of evening and night time snacks provided. A regular supernumery period should be allocated to the senior nurse who supports the registered manager. Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cole Valley Nursing Home DS0000024835.V294229.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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