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Inspection on 01/06/05 for Deerwood Grange Nursing Home

Also see our care home review for Deerwood Grange Nursing Home for more information

This inspection was carried out on 1st June 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.

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 home fully assesses and provides information for prospective residents to ensure their needs can be met and an informed choice made prior to offering accommodation. Staff were seen to be skilled, attentive, respectful and confidential whilst providing care to the residents. Relatives feel the home is good, visiting is flexible and that they are consulted on any changes or developments relating to care. The home has good procedures and practices to allow residents and their representatives to raise concerns and protect residents. This includes good recruitment of staff, ensuring all background checks are completed prior to appointment. The home provides a range of equipment, aids and adaptations to meet the varying needs of residents, e.g. electrically adjustable beds. The home has in place risk assessments for safe working practices which include food safety, staff, building / premises and fire.

What has improved since the last inspection?

The home ensures that the commission is notified of concerns in respect of the well being of residents. All residents are provided with details of the terms and conditions of residency at the home. The supervision of staff is now frequent. The ongoing assessment of residents to identify their changing needs has been improved. Policies including Complaints and Missing Persons have been updated. Minor repairs to ensure the health and safety of residents and staff have been completed.

What the care home could do better:

The home must further develop written care plans to include all the needs of the residents. All residents must be provided with the opportunity to receive a service from other healthcare professionals such as an optician. A full assessment of the nutritional needs of residents is required and the home must ensure that the medication practices in the home are safe. All building work to provide individual accommodation, private toilet areas and structural safety must be completed. Staffing levels need to be increased to enable the home to adequately meet all residents` needs and staff require further training in some aspects of safe working practices such as fire safety and prevention. A system to regularly review the quality of the service needs to be developed and implemented.

CARE HOMES FOR OLDER PEOPLE Deerwood Grange 22 Wentworth Road Four Oaks Sutton Coldfield B74 2SD Lead Inspector Sean Devine Announced 1 June 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. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Deerwood Grange Address 22 Wentworth Road Four Oaks Sutton Coldfield B74 2SD 0121 355 0060 0121 355 0060 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) BAMH (MIND) Ms Carol Mann Care Home 22 Category(ies) of N DE MD (22) registration, with number of places Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That Ms Mann provides proof of successful completion of the Registered Managers Award (NVQ Level 4) by September 2004. Date of last inspection 15/12/04 Brief Description of the Service: Deerwood Grange is a large adapted nursing home in the Four Oaks conservation area of Birmingham. The home is approached from a driveway, and is set back from the main road. To the rear of the building are large gardens, which are utilised by service users in good weather. The home has six single bedrooms and eight double rooms, the organisation is aware that this is not in line with the National Minimum Standards. Plans to redevelop the service users bedrooms have now been received and building work has commenced. This will provide all service users with mainly single bedrooms and only a small increase in numbers accommodated. There are two large lounge areas, and a large dining room. The home provides nursing care to service users over the age of sixty-five with a diagnosis of dementia and/or mental health issues. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken on an announced basis by two regulation inspectors over a period of one day. The inspectors were able to meet with residents, their families and the staff and management team. Records pertaining to care provided and health and safety were seen, a tour of the premises and interviews with staff were completed. Building work to provide an increase in single room accommodation for residents and required improvements has commenced. The care manager has completed the NVQ level 4 (Registered Managers Award) as identified in the conditions of registration. The inspectors would like to thank the residents, relatives and staff for their assistance throughout the inspection. What the service does well: The home fully assesses and provides information for prospective residents to ensure their needs can be met and an informed choice made prior to offering accommodation. Staff were seen to be skilled, attentive, respectful and confidential whilst providing care to the residents. Relatives feel the home is good, visiting is flexible and that they are consulted on any changes or developments relating to care. The home has good procedures and practices to allow residents and their representatives to raise concerns and protect residents. This includes good recruitment of staff, ensuring all background checks are completed prior to appointment. The home provides a range of equipment, aids and adaptations to meet the varying needs of residents, e.g. electrically adjustable beds. The home has in place risk assessments for safe working practices which include food safety, staff, building / premises and fire. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 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 standard(s) 1,3,6 The choice of home and the needs of prospective residents form an integral part of the admission process. The home only provides a placement when it is clear the needs of the prospective resident can be met. EVIDENCE: The home has a statement of purpose and a service users guide that is informative for prospective residents, this will require updating when building work has been completed. Sampled residents files contained pre-admission assessments completed by the management team prior to admission. The assessments detailed the needs of residents. Personal histories of residents were also informative and for some residents used to develop a written care plan. The home does not provide an intermediate care service. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 9 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 and 10. The home does not adequately meet all the health and social care needs of residents, improvements are needed to ensure residents have all their needs met and to ensure they are not at risk. EVIDENCE: Five residents’ written care plans were sampled; they were found to be well written and informed the staff team in how to meet the needs of the residents. It was clear from the assessments and the daily reports that not all needs of residents had been planned for e.g. disturbed sleep patterns, bladder washouts and a sacral pressure sore. Some care plans detailed how the social and recreational needs of residents were to be met, however some did not contain this information. One care plan detailed the social needs of a resident, no records in the past month indicated that the plan had been implemented. The care plans were generally found to be reviewed on a monthly basis, however the reviews did not always indicate the effectiveness of the care planned. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 10 The home keeps records of visits by the GP and chiropodist in the daily records, no records pertaining to optical and dental care were available. It is recommended that healthcare records are maintained separate to daily reports. Risk assessments for example manual handling, tissue viability and the use of bedsides were available. The nutritional needs of residents had not been risk assessed and some records in respect of weight or body mass index had not been completed. The manager confirmed that all staff responsible for the management of medicines had been enrolled onto an accredited course. The medicines for residents are supplied by a local chemist, mainly in the form of a blister pack, however some medicines are boxed or in bottles. The records for the receipt and administration of medicines to residents were found to be well completed, however it was not clear on one record how many tablets were given when the instructions stated one or two tablets to be given. A stock take of medicines found that levels were inaccurate, this was mainly identified in boxed medicines, the manager was requested to address these concerns and take corrective actions. Bladder washouts were not recorded on the medication administration records and were thus not signed for when administered. The homes’ medication policy was seen to reflect current practice for example PRN (as required) medicines had a protocol in place for administration of medicines. The home has a policy covering confidentiality called visions, values and principles, staff were seen to be discreet when discussing the needs of residents in communal areas and respectful when assisting residents; records are stored safely in the office. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 11 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 and 15. The daily life and social activity needs of some residents at the home is actively promoted, however the needs and abilities of all residents is not adequately assessed and planned for. Mealtimes are not a sociable occasion and do not promote the individual ability of all residents. EVIDENCE: The home employs an activities co-ordinator to work eight hours a week with the residents. This includes activities such as ball games, board games, hand massages and shopping with residents. Residents’ files included some assessed information about the lifestyles and history of residents prior to their admission to the home. Some residents had care plans written detailing how they were to be supported to continue these activities such as looking through newspaper articles about boxing and watching boxing on the television, dancing and singing. There was limited information about the lifestyles and pastimes for some residents within the assessment process. The inspectors were able to meet with relatives of residents, the feedback was positive including the home keeping in contact with them, consulting about the care needs, attending residents’ reviews, flexibility of visits and using the garden in fine weather for visits. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 12 Mealtimes were observed, some residents use the large dining area, other residents remain in one of the lounges or take their meals in their rooms. Staff assistance is needed for some resident’s, this was conducted in a respectful and dignified manner, however appropriate crockery needs to be used. The lighting in the dining area is dim, this does not assist residents with visual and cognitive impairments to eat their meals. The dining area had music playing in the background, this was a little loud and not appropriate for a mealtime. Condiments and placemats were not available on the tables or from the hot trolley area where meals were served from, it did appear that some residents would be able to use these items. Menus appear to be well balanced and nutritional, a four-week cyclical menu is operational and the catering team also provide a vegetarian option for all main meals. Storage of food is good, daily temperatures of the fridges and freezers are recorded, however the temperature gauge on one fridge is not working, the manager confirmed that a new fridge has been ordered. Core food temperatures are not recorded for all meat products cooked at the home. The majority of food was labelled with use by dates, however decanted food items such as cheese must also be labelled. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 13 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 and 18 The home has policies and procedures to ensure that areas of concern are raised and effectively addressed, including protecting residents from abuse. EVIDENCE: The home has a complaints policy that has recently been revised, it supports residents and their representatives to raise issues of concern. The home has a complaints log, no complaint has been logged in the past twelve months. The commission has not received any complaints in respect of the service in the past twelve months. The home has an adult protection policy that meets with local guidelines from Social Care and Health. Staffing records in respect of training indicate that staff have received adult protection training and during an interview with staff they demonstrated adequate knowledge of what constitutes abuse and also their responsibilities. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 14 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) All standards. The home does not fully meet the needs of residents in respect of the environment, some areas are unsafe and present a risk to residents. The home is addressing areas of concern and building work has commenced to improve the service. EVIDENCE: A tour of the premises was undertaken, this included all residents accommodation and all communal areas. The home is currently having extensive building work to provide an increase in single room accommodation. The requirements from the last inspection pertaining to building safety and improvements have been carried forward as they are to be addressed during the current building work. The two lounge areas are well maintained and residents are also able to use the dining area for activities. The garden is extensive with ramped access for wheelchairs, the short wall overlooking the lawn area requires repair as the brickwork is crumbled in some areas. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 15 A range of bathrooms and toilets are available for the residents, some have been adapted to meet the mobility needs of residents and all residents’ rooms have a wash hand basin. Specialist care equipment is available at the home including hoists, electrically adjusted beds, pressure relieving mattresses and a call system. The shared rooms must afford adequate privacy for residents, thus privacy curtains where needed must be in place and used. The home maintains a supply of disposable gloves, liquid soap and paper towels in the rooms of residents next to the residents wash hand basins, where this is seen as a specific need for some residents it should not be practice for all residents. Residents are encouraged to have small items of their own furniture and some residents also have their own bed linen. However the majority of furnishings are supplied by the home. A cable from an electric razor was observed to be plugged in and hanging in the wash hand basin, no water was in the sink at the time. This danger was discussed with the manager. The heating, lighting, water supply and ventilation of residents’ rooms was adequate to meet the needs of residents. The hygiene and control of infection practice at the home is being improved as part of the current building work. Whilst the laundry is not in use an external laundry contractor has been employed. A sorting room for all fresh laundry has been identified. The home has battery operated air fresheners appropriately placed throughout the building, one was found to have no aerosol canister. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 16 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) 27,28,29 and 30. Staff are recruited in line with good practice, this helps protect vulnerable residents. Staffing levels and staff training are not adequate to fully meet the needs of the residents. EVIDENCE: The manager confirmed that at the time of inspection the home had in total six care assistant vacancies covering day and night duty and one Registered Mental Nurse vacancy at night. Staff rosters indicate that the home is using agency care staff to cover vacancies. Five staff including a Registered Mental Nurse are required to be on duty during day hours (8am to 10pm), at times only four staff are on the roster. At night the home must maintain a minimum of three staff on duty one being a qualified nurse, as identified at previous inspections only two staff are on the roster. The rosters did not indicate the hours staff actually work. The home has seven care staff of which six have completed NVQ 2 or above in Care. The recruitment files for three staff were sampled. All staff employed had a criminal records bureau disclosure, completed application forms, two written references, identity documents and health screening. The home does train staff in safe working practices such as food hygiene, COSHH and manual handling. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 17 One member of staff who is employed as a domestic assistant had not received infection control training. Fire safety training is undertaken however records did not indicate that this was completed twice annually. The home also provides service specific training such as Dementia awareness and social aspects and risk assessing. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 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 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) 33,35,36,37 and 38, The home does not fully ensure that the management and the administration of the home is of a standard that will ensure the quality and safety of the service for the residents. EVIDENCE: The manager confirmed that no progress had been made in consulting and seeking the views of residents, their representatives and stakeholders in respect of its performance against its stated purpose. The home does not manage any money on behalf of the residents, the preinspection questionnaire indicated that relatives receive the personal allowance of the residents. This was confirmed by a relative who stated that staff make relatives aware of when items such as toiletries, clothing and personal items are needed. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 19 Staff are receiving regular supervision from the management team. This includes required training and any personal concerns. Records seen did not indicate that the performance of staff is monitored and that the ethos and philosophy of care is on the agenda at supervisions. Trained nurses are receiving external and internal clinical supervisions, the manager needs to ensure that these supervisions are fully recorded. The home has policies and procedures that are informative and clear for staff to enable them to undertake their duties effectively and in line with legislation and best practice. Those policies seen included Missing Persons, Complaints, Adult Protection, Confidentiality, Visions Values and Principles and the Accident Policy. In respect of safe working practice the home has maintained the appropriate tests and service in respect of gas and water safety. The fire system is tested and serviced, however the manager is aware that following the completion of building work a periodic electrical installation test is needed. The emergency lights are not tested every month. Staff are attending fire drills, records did not indicate that this is completed a minimum of twice yearly. The home is recording accidents to residents and staff appropriately, the manager should ensure that audits of these accidents are undertaken and that trends are acknowledged and managed. The home has in place risk assessments for safe working practices which include food safety, staff, building / premises and fire. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 2 2 3 3 2 2 2 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 1 x N/A 2 3 2 Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 21 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. 2. Standard OP7 OP7 Regulation 15(1) Requirement Timescale for action 31/7/05 31/7/05 Written care plans must be completed to meet all the residents needs. 15(2)(b)(c Written care plans must be )(d) reviewed and inform whether or not the plan is effective. Previous timescale of 31/5/05 not met, this requirement is carried forward. All residents must have their dental and optical care needs assessed and records must be maintained. Previous timescale of 31/5/05 not met, this requirement is carried forward. A nutritional risk assessment / screening for all resdients must be undertaken and periodically reviewed. Residents written plans to treat and promote healing of pressure or other wounds, must be reassessed / reviewed following each change of dressing. The home must ensure that clear information as to size and grade of wound is indicated at each review. 3. OP8 12(1)(a) 13(1)(b) 31/8/05 4. OP8 12(1) 13(4)(c ) 13(1)(b) 15(1) 31/8/05 5. OP8 31/7/05 Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 22 Previous timescale 30/04/05 not met, this requirement is carried forward. All pressure sores / wounds must have a written plan of treatment. All medicines must be audited, 15/6/05 any discrepancies must be fully investigated and corrective actions taken. It must be clear on the medication administration record how many tablets have been administered. All medicines must be signed when administered including bladder washouts. Residents files must include an assessment of meaningful activity, hobbies and interests and a plan must be developed detailing how these needs will be met. Previous timescale of 31/5/05 not met, this requirement is carried forward. The environment and facilities must be reviewed and corrected at mealtimes to include; lighting, radio noise, the availability of condiments, placemats and table cloths. Plastic crockery must only be used where there is an assessed specific risk. All decanted food items stored in the fridge must be appropriately labelled. The core food temperatures of all cooked meats must be taken and recorded. The temperature gauge on one Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 23 6. OP9 13(2) 31/7/05 31/7/05 31/8/05 7. 8. OP9 OP12 13(2) 16(2)(m)( n) 9. OP15 16(2)(g) 12(4)(a) 31/7/05 10. OP15 16(2)(g) (i) 31/7/05 fridge must be repaired. 11. OP19 23(2)(b) Repairs are necessary to the first floor bathroom where there is a large crack in the wall. The damaged paintwork on service users doors must be repaired. Previous timescale of 30/6/05 not met, these requirements are carried forward. The garden wall must be repaired. Privacy curtains must always be fitted in shared rooms. The manager must ensure that all toileting facilities are of a design that promotes privacy of the residents. All toilets walls and doors must extend from floor to ceiling. Previous timescale of 30/6/05 not met, this requirement is carried forward. The shaving leads of residents must be unplugged after use and put away. The manager must audit the furniture and fittings in residents rooms, any gaps must be addressed or alternative provision made. This must be reflected in the homes statement of purpose. The manager must consult the service users and next of kin about the gaps and alternative provision. Previous timescale of 30/6/05 not met, these requirements are carried forward. The battery operated air fresheners where used to control odour must be maintained in 31/10/05 12. 13. 14. OP19 OP20 OP21 23(2)(b) 16(2)(c ) 23(2)(a) 31/10/05 31/7/05 31/10/05 15. 16. OP24 & 38 OP24 13(4)(c ) 16(2)(c ) 31/7/05 31/8/05 17. OP26 16(2)(k) 31/7/05 Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 24 working order. 18. OP27 18(1)(a 17(2) schedule 4 (7)) The manager must ensure that there is a minimum of three staff on night duty, one must be a trained nurse. Previous timescale of 31/5/05 not met, this requirement is carried forward. The manager must ensure that there is a minimum of five staff on day duty (8am to 10pm). New staff must be recruited to current vacancies. The staff roster must fully reflect the hours that staff actually work. 13(4)(a)(c All radiators in service user ) bedrooms must be fitted with covers or be replaced with low surface temperature emitters to reduce the risk of scalding. Previous timescale of 30/6/05 not met, this requirement is carried forward. All staff must receive the following safe working practice training. Fire safety and prevention, twice yearly. Infection Control. Basic Food Hygiene. Previous timescale for Basic Food Hygiene of 30/4/05 not met, requirement is carried forward. The manager must ensure that 30/9/05 regular consultation, which is recorded is undertaken, to elicit its performance against the statement of purpose, aims and objectives. This must include e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 25 31/7/05 30/9/05 31/7/05 31/10/05 19. OP25 20. OP30 18(1)(c )(i) 30/9/05 21. OP33 24 Deerwood Grange residents, their representatives and stakeholders. Previous timescale of 30/6/05 not met, this requirement is carried forward. Staff must receive supervision that includes details of 36.3 of the National Minimum Standards for Older People. 22. OP36 18(2) 31/8/05 23. OP38 13(4) The clinical supervision for trained nurses must be recorded. A staff risk assessment must be 31/8/05 completed to ensure the safety of residents and staff when working in confined spaces such as using hoists and wheelchairs in shared rooms, e.g. Room 12. Previous timescale of 31/5/05 not met, this requirement is carried forward. All staff must take part in a fire drill at least twice each year, with records fully maintained. Previous timescale of 23/12/04 not met, this immediate requirement is carried forward. The manager must ensure that the electrical hard wiring is tested for safety and that a certificate confirming the safety is available. Previous timescale of 30/6/05 not met, this requirement is caried forward. The emergency lights must be tested on a monthly basis. Records must be available. 24. OP38 23(4)(a)( e) 15/6/05 25. OP38 13(4)(a) 31/10/05 26. OP38 23(4)(b) 31/7/05 Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 26 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 OP8 OP38 Good Practice Recommendations It is recommended that healthcare records are maintained separate to daily reports. It is recommended that the accidents at the home be audited on a regular basis. Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 Page 27 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 Deerwood Grange e54_S24837_Deerwood_V223372_010605 - Stage 4.doc Version 1.30 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. 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