Inspection on 31/08/05 for Colebrook Respite Unit

This inspection was carried out on 31st August 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

Colebrook Respite Unit 20/05/08

Colebrook Respite Unit 11/06/07

Colebrook Respite Unit 31/10/06

Colebrook Respite Unit 14/02/06

Colebrook Respite Unit 07/03/05

Colebrook Respite Unit 09/09/04

Colebrook Respite Unit 19/01/04

Similar services:

Coton Hill House

Doddington Lodge

Far Croft

Churchill House Nursing and Residential Home

Field Farm House

Church Terrace Nursing & Residential Home

Fountain Court

The Forbury

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

CARE HOMES FOR OLDER PEOPLE Colebrook Respite Unit 291 Bosworth Drive Chelmsley Wood Solihull B37 5DP Lead Inspector Jill Brown Unannounced 31 August 2005 st 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. Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Colebrook Respite Unit Address 291 Bosworth Drive Chelmsley Wood Solihull B37 5DP 0121 770 6133 0121 770 6144 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) Family Care Trust (Solihull) Mrs Anne-Marie Yardley Care Home 7 Category(ies) of Care Home registration, with number of places Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home can accommodate up to 7 older people who also suffer from dementia on a respite basis... Date of last inspection 07 March 2005 Brief Description of the Service: Colebrook Respite Centre is part of the Family Care Trust Organisation. They provide a respite service for people with dementia. Respite is usually offered for up to six weeks but can be extended depending on circumstances. Most residents are admitted after a planned admission programme however the home can after consideration provide emergency placements. Six of the beds provided are funded by Solihull Social Services on a block contract and one bed is available for privately funded people. Residents are aged over 65 years and over and have to be mobile independently or walk with a walking aid. All the centres accommodation is at ground floor level and accessible by people with disabilities. Two of the bedrooms have ensuite facilities. The centre has an assisted bathing and a separate assisted shower facility. The centre has several communal areas that are shared with the day centre. One of these is a quiet lounge. A day centre facility is also run from the same premises. The company has a minibus, which it uses to and from the day centre and for trips for residents. Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over approximately 5 hours of a day in late August. Three people were resident in the respite centre at the time of the inspection and a further person was in hospital. The Deputy Manager was on duty at the time of the inspection the Manager being away on annual leave. A tour of the building and garden was undertaken and some maintenance and inspection records of the building were sampled. Care records for two residents were looked at, as well as accident, complaint records and a staffing rota. A meal was taken with the residents and the day centre attendees. What the service does well: What has improved since the last inspection? The inspector was new to the centre and accepts that improvements may be difficult for her to measure. Some outstanding requirements could not be assessed due to inability to access records. The staffing at the main mealtime was now appropriate to the number and needs of residents and day centre attendees. Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 6 Maintenance and inspection records in the main were available and showed that the centre was meeting these requirements. What they could do better: The centre had taken a person for respite that was not 65 years old. Although this was outside the centre’s condition of registration, the person was suitable for the centre. The registered manager must ask for variation to make future admissions of this person possible and it is recommended that vary the conditions so that no more than 2 persons under 65 with dementia can be accommodated at any one time. Assessments for admission to the centre for respite were not in enough detail to make sure that a person’s usual pattern of life was not unduly disrupted and things were done in the way the person liked. There was no check made to see if there were any changes in the resident’s health and well-being before being admitted for a further respite stay. This could result in residents not getting the care they need if their health needs had changed. The centre did not monitor residents’ weights and food intake. There were not enough checks on medication before admission to make sure it was complete and still right. The medication records held by the centre were poor. There were no care plans for residents showing how staff were to provide the care for each resident. There was no evidence of risk assessments for key areas such as nutrition and behaviour where these were needed. The centre could not show how residents were enabled to make choices about their care and food. A number of the carpeted areas in the centre were a bit stained as result of heavy use and there were a few areas where improvements could to be made to make it easier for staff and residents. The centre’s record keeping and reporting needed to improve to ensure that the Commission was kept informed. The Commission must be informed of the monitoring visits done by the responsible individual and any accident that involves a person on respite at the centre. Some records were not available for inspection on the visit. A record had been changed using Tippex and this is not good practice because it can allow records to be falsified. The centre needed to change its missing person’s policy to make sure that everyone is informed when someone goes missing and that the person has a health check on return to make sure they are well. A number of health and safety issues needed to be put right to ensure the continued safety of residents. These were about fire doors, the securing of Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 7 wardrobes and cupboards so they cannot be pulled over, and a five year wiring check of the centre. 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. Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.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 Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.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) 1,3,4 & 5 Assessments done by the centre and funding authority were not kept up to date and did not ensure that needs were identified. This lack of attention to detail could potentially put residents at risk. The centre did ensure where possible that residents visited the centre before admission and this helps residents when they are admitted. EVIDENCE: One person was resident on respite that did not meet the age criteria. Although the inspector agreed that the placement was appropriate a variation to the centre’s registration is required. The centre’s statement of purpose must be revised in the light of this variation. Both pages of the centres certificate of registration were not displayed in a public area. The centre had assessments from social workers prior to the first admission of the resident and the centre then undertook their own assessment. Jointly the assessments did not provide enough personal information on existing routines and preferences of residents for these to be maintained during the placement. This lack does not facilitate choice and could disorientate some residents on their return home. Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 10 There was no record of assessments being checked for changes of need before further admissions. In one example the resident had not been at the centre for six months and it was unclear if the resident had needs ad changed or were being met. None of the people receiving respite were non-white or non UK citizens however the deputy manager appeared aware of the needs of potential residents and accepted that a full assessment of lifestyle would be important. Some of the people that have respite at the home have previously had day care at the centre or at one of the other day centres the Family Care Trust owns and this enables a smooth move to respite care. Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.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) 7,8,9 & 10 The arrangements for planning for and monitoring needs were poor and this could put residents at risk. However physical care was given appropriately and sensitively and in this way residents were well cared for. The arrangements for the administration of medication were poor and the gaps in practice potentially put residents at risk. EVIDENCE: The inspector could not find a clear care plan on the files viewed although was told these were now in progress. Risk assessments were not in evidence although it was clear residents did have behaviour that required management. Daily records did not demonstrate that residents’ patterns of life were continued or where this, for health and safety reasons, needed to be changed a clear plan was not found. The inspector found residents physically well cared for with hygiene needs met. It was clear that the home worked hard to ensure that this was true for all residents. Residents’ clothes were well laundered. Falls were recorded and monitored. Weights were not recorded at the beginning and at the end of Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 12 stays and monthly for longer stays and did not link into records of food eaten or nutritional assessments. The centre takes over responsibility for administering medication whilst residents are on respite. The amount of medication given could not be audited, as details of the amount of medication were not recorded on admission. Appropriate checks were not in place to confirm that: - medication brought in was correct, had details of how to administer and was logged appropriately into the centre’s records. Medication was found not in a locked cupboard. The inspector found that all staff treated the residents and day centre attendees with respect. They took great care to explain and involve residents with anything that was happening. Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.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, 13 ,14 & 15 Arrangement for activities and visitors was good and these enhance residents’ lives. The centre could not show how choice of lifestyle was maintained in respite care. EVIDENCE: The home has a programme of activities usually one activity in a morning and one in the afternoon. Both residents and attendees of the day centre can attend. On the day of the inspection these activities were singing, talking outside in the garden and a quiz. There were some displays of residents’ histories on the wall that showed that individual staff time was taken in talking to residents. The inspector noticed that residents were given individual time throughout the day. During the inspection a residents relatives were visiting and there appeared to be no undue restrictions on visiting. Daily records suggested that residents were approached to get up by night staff when this was not the pattern of behaviour at home. The records did not suggest a health reason for this. Information held about residents did not give enough detail to ensure individually appropriate activities. Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 14 The food for the main meal of the day was well presented and cooked. Residents and day centre attendees were given a roast pork dinner with two vegetables mashed and roast potatoes with apple pie and custard for pudding. Residents and people attending the day centre clearly enjoyed the meal and the portions of food provided were ample. There was no evidence of a formal choice of meal although it was reported that residents could have something else if they did not like the meal prepared. The amount of food residents had eaten was not recorded in consistent and easy retrievable fashion and this was especially true of other meals such as breakfast and tea where residents could have a large individual choice of food. This does not allow tracking where residents are losing weight for foods that are being eaten or for clear information to be given to medical staff. Residents that required assistance to eat were given this help sensitively. Residents were encouraged to maintain a good eating posture. Where necessary encouragement to maintain concentration on eating was given. Strategies about assisting residents that have sight loss at meal times would be useful. Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 15 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) 16 EVIDENCE: These standards were not inspected on this occasion. Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 16 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, 20, 21, 22, 23, 24, 26 The centre has good accommodation for residents and day centre attendees; some improvements to maintenance would improve these and assist residents. EVIDENCE: The centre was clean and fresh on the day of the inspection. The centre had a good range of communal areas for both activities and quiet spaces and met the required standard on this space. The centre has good bathing facilities with both an assisted bathing and an assisted shower available. The bedrooms were well decorated and furnished in attractive colours. These appeared a little empty as residents’ spend only respite time at the centre and do not bring in many personal items. The inspector was told that bedrooms have floor sensors so that staff can be alerted to residents that are walking during the night. The bedrooms of the Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 17 respite area could be sectioned off to ensure staff could see residents during the day. However a protocol must be in place for residents that wish to spend time in their room especially because of the location of hot food lockers, the kitchen, the laundry and the staff room. The main communal areas have good signage but some areas could use some developing clear colour codes, for example bathrooms, toilets and en suites. Some areas of the home require some thought to maintenance of décor. A number of carpets were showing heavy use, one bedroom’s walls needed cleaning and extending the tiling around communal wash hand basins would assist cleaning. The centre has a safe enclosed garden. The centre’s garden shed must have an appropriate lock. The home has a laundry and provides a laundry for people external to the home a protocol must be written to ensure that good infection control procedures are maintained. Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 The centre was appropriately staffed at the time of inspection. EVIDENCE: The number of staff on duty was appropriate at the time of the inspection. Staffing level fluctuates with the number of residents having respite at any time. The dependency levels of the day centre attendees were assessed on a routine basis. This assessment showed the number of day centre places the centre could manage. This formal assessment could usefully be extended to the respite residents especially when the respite centre is full. The manager of the centre was on annual leave at the time of the inspection and staff files could not be inspected. Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.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) 37 & 38 Record keeping and reporting needed improvement to ensure residents’ best interests. A number of health and safety issues need to be addressed to ensure the continued safety of residents. EVIDENCE: The inspector saw a missing persons procedure on display. This was found not to have the requirement to contact relatives, funding authority or the Commission. It did not instruct staff to ensure that the person was well on return. There was a clear emergency admissions procedure. Tippex had been used to alter a record and this is not good practice because it can allow records to be falsified. Records were not available and this had been required previously. The Commission had not received the reports of the responsible individual’s monthly visits, as required; the latest found in the home was dated May 2005. A check of the centre’s accident records showed that the centre did not have Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 20 an undue amount of accidents, but they did not report accidents of people receiving respite to the Commission. Fire checks were being undertaken but the inspector was concerned that the fire door leading from the staff room was restricted by furniture and a coat stand. One fire door was wedged open and this seemed to be a regular occurrence at the point of meals being placed in the hot lockers. The location of hot lockers remains of concern as residents are at risk of burns if residents allowed access to their bedrooms when they want. The centre had a Landlords gas certificate in place and lifting equipment was being maintained. The five year wiring check was not found during the inspection. The centre had checks to ensure that all fire equipment, alarms and drills were in place. The centre had the appropriate liability insurance. A previous requirement to ensure that wardrobes were secured to the wall had not been acted upon. Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.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 x 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION 2 3 3 2 3 2 x 2 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x 2 2 Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.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 op1 Regulation 4(1) Requirement The Centres statement of purpose must be reviewed and revised in line with the appropriate variations. The Centres full certificate of registration must be displayed. The centre must ensure that a detailed assessment is undertaken and this takes account of the residents wishes and feelings. Assessments must be reviewed before each subsequent placement. Unless the time between is less than three months and the centre has not been advised of any deterioration in health. The centre must not admit residents outside of its category of registration and It is recommended that a variation is sought to make this unlikely in future. The registered manager must ensure:Care plans reflect the current Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Timescale for action 31/10/05 2. op3 14(1) 12(3) 30/09/05 12/09/05 and ongoing 3. op4 Care Standards Act 2000 sec 24 12/09/05 30/09/05 4. op7 15(1)(2) 12(2)(3) 30/09/05 Page 23 Version 1.40 needs of residents and clearly inform the care staff on care to be given or action to be taken. Care plans are regularly evaluated There is demonstrable evidence that where possible families are involved in the care planning process. The residents social history is recorded where possible. Risk assessments are undertaken for identified risks such as pressure area care, behaviour that challenges, mobility and so on. (The requirements on this standard remain outstanding since ) The registered manager must ensure that records are kept of residents weights and where there are unplanned losses or gains take appropriate action. (this requirement remains outstanding since 31.05.05) Medication must be checked with prescribing GP practice before admission to ensure it remains correct. The amount of medication brought it the centre must be recorded on the medication administration record (MAR). 31/10/05 30/09/05 30/09/05 30/09/05 5. op8 12(1) 30/09/05 6. op9 13(2) 12/09/05 12/09/05 All handwritten MAR must have 30/09/05 two signatures to ensure that the details are accurate. Medication received in a secondary dispenser must have clearly marked the medication Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc 30/09/05 Version 1.40 Page 24 names dose and description. All medicinal creams must have recorded details how, where and when it must be applied. Where medication is not given for any reason, the reason must be written on the reverse of the MAR. Medication that needs to be kept in fridge must be kept in a locked fridge. Records of the current, maxium and minimum temperature of the fridge must be maintained to ensure medication is stored within its product license. The registered manager must undertake audits of staffs competence in administering medication. All medication that is in the centre must be contained in a locked cupboard. The centre must devise a procedure that reflects good practice and ensure its implementation. 7. op14 12(3) The centre must show how residents lifestyle choices are maintained. If for risk or health reasons these are not to be maintained this must be clearly recorded. Residents of the centre must be offered a choice of main meal. A record of the food eaten by individual residents including amount must be kept for all meals. Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 25 30/09/05 30/09/05 30/09/05 30/09/05 30/09/05 30/09/05 30/09/05 8. op15 16(2)(i) 30/09/05 9. op19 23(2)(d) An audit of carpets must be undertaken and action taken to remove staining. One bedroom wall must be investigated for black marks are a result of damp or requires cleaning. The garden shed must have a lock. A protocol must be written about residents safe access to their bedrooms during the day due to identified risks. The registered manager must assess dependency levels of the residents as well as day centre attendees when determining the staffing levels. All accidents, falls and events that affect people staying at the centre for respite must be reported to the Commission. (This remains outstanding since the 22/03/05) Tippex must not be used on records. A Copy of the report of the monthly visits by the responsible individual must be sent to the Commission. The missing person procedure displayed must be adapted to ensure that all relevant parties are contacted including the Commission. Residents must have a health check on return to the centre. The centre must ensure that all records are available for inspection in the managers absence. (this remains outstanding since 31/10/05 30/09/05 30/09/05 30/09/05 10. op24 13(6) 11. op27 18(1)(a) 31/10/05 12. op37 37, 17(1)(a) schedule 4(16) 26 17(3)(b) 30/09/05 30/09/05 31/10/05 31/10/05 30/09/05 Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 26 the 22/03/05) 13. op26 13(3) The registered manager must produce a protocol to ensure that good infection control procedures are maintained with external laundry. The area where the hot lockers are stored during the day for the other day centres must be free from risks to residents and staff. (this regulation remains outstanding since 22/03/05) The storage room containing kitchen equipment must be locked when not in use. (this requirement was not assessed on this occasion) 31/10/05 14. op38 13(6), 13(4)(c) 23(2)(b) 23(4)(b) (e) 30/09/05 30/09/05 Water temperatures in the 30/09/05 assisted bath must be tested and recorded before a resident takes a bath. (this requirement was not assessed on this occasion) Wardrobes must be secured to the wall where necessary. (this requirement was oustanding since the 31/05/05) 30/09/05 A certificate for worthiness of the 30/09/05 electrical wiring must be sent to the Commission. (this requirement remains outstanding since 30/04/05) Fire doors must not be wedged open. The fire door to the hot lockers must have a magnetic door stop tied into the alarm. Fire exits must have clear access. It is recommended that clarification is sought about the Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc 30/09/05 30/09/05 30/09/05 Version 1.40 Page 27 need for fire exit from the staff room. 15. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard op15 op21 op22 Good Practice Recommendations It is recommended that the centre develop strategies to assist residents with sight loss at meal times. It is recommended that the centre consider increase the tiled area around wash hand basins in communal toilets to improve the ease of cleaning. It is recommended that the registered provider considers colour coding doors to toilets bathrooms and en suites to assist residents. It is recommended that some identification is given to bedrooms to assist residents. Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection Birmingham and Solihull Local 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 Colebrook Respite Unit E54 S4527 Colebrook V247558 310805 Stage 4.doc Version 1.40 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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