Inspection on 19/05/05 for Dorcas House

This inspection was carried out on 19th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dorcas House 03/06/08

Dorcas House 06/11/07

Dorcas House 02/05/07

Dorcas House 21/11/06

Dorcas House 23/05/06

Dorcas House 26/10/05

Dorcas House 08/09/04

Dorcas House 25/05/04

Dorcas House 24/11/03

Dorcas House 15/07/03

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

CARE HOMES FOR OLDER PEOPLE Dorcas House 56 Fountian Road Edgbaston Birmingham B17 8NU Lead Inspector Kulwant Ghuman Un announced 19th May 2005 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. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dorcas House Address 56 Fountain Road, Edgbaston, Birmingham, B17 8NU 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) 0121 429 4643 0121 429 4643 Mrs Kate Danquah Mrs Kate Danquah Care home 11 Category(ies) of Mental Disorder - Over 65 (11) registration, with number of places Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That four named persons under 65 years of age at the time of admission can continue to be accommodated and cared for in this Home. 2. The home must demonstrate through comprehensive care planning and regular reviews carried out by Social Services that it is able to meet all the needs of each individual. 3. The home must not in future admit any other persons under the age of 65 years. Date of last inspection 8th September 2004 Brief Description of the Service: Dorcas House is an adapted domestic property that accommodates 11 people who are users of mental health services. The home has three floors with accommodation for service users on two of these. The third floor is for staff use. One lounge has a door out onto the rear garden and contains a large screen television and comfortable seating. Communal space is also provided in the form of a lounge/diner. Service users were seen to sit here to eat, to play games at a dining table and to watch television. The home has both single and shared bedrooms situated on the ground and first floor. A stair lift is available for service users to access the upper floor. There are shower, toilet and bathing facilities on both floors but none of these provide an assisted bathing facility. Laundry facilities are provided at the neighbouring house owned by the Danquah family. At the front of the home is a steep drive on which three cars can be parked. The side gate to the property permits further parking for up to three vehicles. At the rear of the home is a pleasant garden with seating, which service users can enjoy in fair weather. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two inspectors over one day during May 2005. There were 8 residents in the home at the time of the inspection, two others were in hospital and there was one vacancy. Inspectors toured the building, spoke with all the residents, one member of staff and sampled some documents. What the service does well: What has improved since the last inspection? What they could do better: The home must develop the care planning, assessment processes and daily recordings for residents to enable the manager to assess whether the needs of the residents are being met as required. Risk assessments must be a true reflection of the situation of residents and include how the risks are to be minimised. Recruitment, induction, training and supervision of staff must be improved to ensure that the residents are cared for by staff that are suitably trained. Several areas of the home need to be redecorated and the furniture in the bedrooms needs to be replaced as part of a refurbishment programme. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 6 There were several areas of health and safety that the home must attend to including the management of medicines, restriction of hot water temperatures, ensuring that there is adequate lighting in all areas of the home and maintaining adequate infection control procedures. 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. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - 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 Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - 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) 1,2,3,4,5 The home had a statement of purpose and service user guide in place, however, it needed to be amended to ensure that prospective residents were clear about the needs that the home could meet. The manager needed to ensure that the full assessment carried out by the placing authority is obtained prior to admission so that residents can be assured that their needs can be met by the home. EVIDENCE: There was a service user guide and statement of purpose available for residents to access however they needed to be amended to ensure that they reflected where the home does not meet the National Minimum Standards including bedroom facilities and bathing facilities. It needed to make clear that although registered for residents over 65 years of age there were limited adaptations in the home and that residents needed to be fairly mobile. The files seen by the inspectors had an appropriate terms and conditions of residence available on them. Residents were admitted to the home following an assessment by the placing social worker. Some of these assessments contained very little detail and the manager must ensure that a copy of the full assessment is received by the home. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 9 There was evidence on one of the files that an interview/assessment had taken place before the individual was admitted to the home. The home’s statement of purpose states that an opportunity to visit the home and have a meal with the other residents would be given to prospective residents before they moved into the home on a trial basis. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 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 standard(s) 7,8,9,10,11 Care plans were lacking in detail and did not provide staff with sufficient detail to enable them to meet the individual needs of the residents’. The systems for medicine management within the home were poor. These need to be enhanced to ensure residents medication needs are met. Privacy and dignity in the home could not be guaranteed. EVIDENCE: The care plans examined by the inspectors contained very little information about the needs of the residents and how the staff were to assist them in meeting their needs. The care plans needed to be comprehensive and cover all areas of care including personal, health and social care. They need to make clear to the staff how much assistance is required and how it is to be provided. The plan needed to indicate what actions must be taken in the event of deterioration in the mental health of the resident and the indicators that would alert the staff to this deterioration. Staff made a recording on a daily basis however the comments made in some of these recordings indicated that some staff have little understanding of the needs of the residents, for example, ‘good day remains demented’ and all entries are almost the same. There was a record to indicate that the plans were being reviewed on a monthly basis however they provided no information as what areas had been reviewed. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 11 The issue of developing the care plans has been raised at previous inspections but little progress has been made on them. Risk assessments did not always clearly identify all the risks as with the resident who kept all her belongings in the middle of the bedroom. No tissue viability assessments or nutritional assessments were seen on the files. There was evidence that residents were having their health care needs met via visit from the GP, chiropodist and specialist consultants at the hospital however these were not maintained in a consistent manner. There was some evidence that residents weights were being monitored but these were not being undertaken at regular times and where there was a loss of weight it was not clear whether any follow up actions had been taken. The home had no medication policy to adhere to. One member of staff had signed the administration of all the doses for 24 days on the Medicine Administration Record (MAR) chart despite two staff members being responsible for medicine administration through the day. It could not be demonstrated that the MAR chart was referred to prior to the drug administration. Medicines had been signed as administered when they had not been in some instances. Conversely one medicine was unaccounted for. The prescriptions are seen prior to dispensing and photocopied. These are not adequately used to check the medicines into the home. Hand written additions to the MAR chart were poor. No carry over balances had been routinely recorded, the strength of one tablet was incorrectly recorded. Medicines were found in a cupboard in another area in the home with no explanation why. These were not stored alongside the medicines for administration. The home did not have a current returns book used to record medicines returned to the pharmacy for destruction. The staff recorded the receipt of medicines but these did not always reflect the quantity actually received into the home. The pharmacy supplied the medicines in a Monitored Dosage System, which had aided the safe administration of the majority of medicines within the home. Shared rooms had screening rails fitted, however, the curtains were noted to be inadequate in size to ensure privacy and dignity. The locks on bedroom and bathroom doors were not acceptable. The bedroom doors could not be opened from the outside in an emergency and some of the toilet and bathroom doors could not be locked. The home had gathered some information about the wishes of residents in respect of the actions to be taken in the event of death. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 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 standard(s) 12,13,15 It was difficult to evidence whether the needs of the residents recreational needs could be met as the care plans did not adequately indicate how these needs were to be met. The food provided was of an acceptable standard however not all residents’ dietary preferences were met. Food stock levels were allowed to fall to unacceptable levels. EVIDENCE: It was difficult to evidence whether the needs of the residents recreational needs could be met as the care plans did not adequately indicate how these needs were to be met. Residents were seen to be watching the television in the lounge/dining room. A male resident was seen playing dominoes. Two other residents were in their bedrooms occupying themselves. One resident was seen to wander around the home engaging in some repetitive conversations with the inspectors, however, no interactions were observed with the staff. There was evidence that residents’ visitors were able to visit the home at all reasonable times. Residents stated that the food received was plentiful and enjoyed by them. One of the residents who ate a lot of fruit stated that she had not had fruit available for several days. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 13 The proprietor stated that he had been unable to get the fruit over the past few days and fruit had been brought in by the end of the inspection. Another resident stated that they would like to have a cooked breakfast and steak sometimes but this was not available. In general, the food stocks in the home were low. The inspectors were informed that shopping was to be carried out that day. It is not acceptable to allow food stocks to run so low on a regular basis. The inspectors were told that portions of food that were pureed or softened were kept separate on the plate. Choices needed to be made clear on the menu and the menu needed to be shared with the residents as none of them were aware what the meal for that lunchtime was. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Adequate policies were in place for the protection of residents. EVIDENCE: There was a complaints procedure in the service user guide that appeared to be satisfactory, however, there was residents complaint procedure that needed to be taken out of use as it referred to the Inspection Unit, that no longer existed. There was an adult protection procedure and whistle blowing policy in place. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 The physical environment was suitable for residents with a good degree of mobility. Several issues remained outstanding from previous inspections, which needed to be addressed to ensure that the needs of the residents could be met in a safe and comfortable environment. EVIDENCE: The main lounge was used by residents who wanted some peace and quiet. Most residents sat in the lounge/dining room, which was pleasant and comfortable. The garden required some attention to the relaying of slabs and general tidying up. The home was suitable for residents who had good mobility as there were no assisted bathing facilities and the only adaptations in the home were a stair lift to the first floor and an emergency call system. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 16 At the time of the inspection the residents did not need to be hoisted in and out of the baths. There was a bath seat that was broken and taken out of use as it posed a risk of injury to the residents. The hot water being delivered to the bathroom, and shower on the ground floor, was too hot. Water from the shower would make the floor slippery putting staff and service users at risk. The manager should consider the installation of folding doors that would minimise this risk. The toilet by the kitchen had a broken toilet seat, no call system, and no lock on the door and the door required fixing so that it could be closed. Several light bulbs in the bathroom, toilet, bedrooms and corridors were not working. The inspectors were told that they keep fusing. The wiring system must be checked if this continues to happen. Some bedrooms had personal items in them however the furniture continued to be worn and in need of replacement. Several of the bedrooms did not have bedside cabinets, comfortable chairs, individual wardrobes in shared rooms and bedside lighting. The statement of purpose needed to reflect where the furniture was not as laid out in the national minimum standards. There were some dirty carpets, stained mattresses and odour in some areas of the home that needed attention. Liquid soap and paper towels needed to be available in all bathrooms and toilets, and, the seat in the shower needed to be cleaned. Disposable gloves needed to be disposed of in clinical waste bags. The laundry was located in the house next door that was also owned by the proprietors. On the day of the inspection the laundry area was very cluttered with the residents’ laundry and the proprietors family laundry in there. There was a washing machine that the inspectors were told had a sluice cycle however the inspectors were unable to determine which cycle would be used. The proprietor was unable to find any documents that could show that this facility was available on the machine. A system needed to be put in to keep clean and dirty laundry separated. In the main kitchen there were some broken floor tiles that needed to be replaced. The tap was missing off the wash hand basin and the cooker was positioned behind the door that could potentially cause an accident. The manager should discuss with the fire officer the possibility of having a glass panel in the door so that it could be seen if anyone was behind the door. There were foods in the freezer that were not dated and food was not being probed to ensure that it had reached the required temperature. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The homes recruitment practices and staff training did not evidence that service users were in safe hands at all times. EVIDENCE: There were due to be two carers and the manager on shift during the morning of the inspection however one person did not turn up for duty. The proprietor was available to assist. During the afternoons two people were on duty. Staff took a multi-task role in the home undertaking cooking, cleaning and caring roles. At the time of the inspection there were 8 residents in the home and their needs could be met by the numbers of staff on duty. The staff files sampled indicated that either CRB checks were not in place or had not been received before the member of staff had commenced employment. Not all the required information was available on the staff files including training, proof of identity, photographs, induction or supervision. The registered manager needed to ensure that staff received training to equip them to care for the residents in the home. This would need to include an awareness of mental health conditions, the illnesses of old age and adult protection in addition to the basic mandatory induction and foundation training and training in first aid, food hygiene, fire prevention and infection control. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - 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) 31,36,37,38 The home had a stable management team, however, robust recruitment procedures, leadership and training were needed in order to ensure that staff provided appropriate care in a safe environment. EVIDENCE: The registered manager was undertaking the NVQ Level 4 in care and management. The manager needed to improve the assessment and care planning processes in the home and ensure that the daily records were completed so as to provide an overview of the resident’s day and the care offered. The manager was approachable and willing to take on board some of the comments made by the inspectors. Staff had not been supervised by the manager on regular basis. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 19 Procedures sampled included missing persons and adult protection, which were acceptable. The accident procedure required further development. The accident books and other records were kept in an office on the top floor that the inspectors did not see. There were some issues of health and safety that the manager needed to attend to and these included:The locking away of Steradent tablets. The restriction of hot water temperatures to 43 degrees centigrade. Administration of medicines. Lights being maintained in working order. Fire Risk Assessment. Testing for Legionella. 5 yearly electrical testing and portable appliance testing. Servicing of the chair lift. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - 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 2 3 2 2 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 1 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 2 2 2 3 2 1 1 STAFFING Standard No Score 27 2 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 1 x x x 1 2 1 Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 21 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&5,1 Requirement Amendments must be made to the service user guide and statement of purpose. (Previous timescale of 30.11.04 not met.) The registered person must ensure they obtain a copy of the assessment carried out by the placing authority. The residents care plans must be developed to clearly show the needs of each person and how the staff were to meet the identified needs. (Previous timescale of 30.11.04 not met.) Strategies for dealing with difficult and challenging behavour must be included in the plan. (Previous timescale of 30.11.04 not met.) Care plans must be reviewed monthly and formally every six months. (Previous timescale of 30.11.04 not met.) Risk assessments must be holistic and identify how they are to be managed. Residents weights must be Timescale for action 1.8.05 2. OP2 14(1)(b) 1.7.05 3. OP7 15(1) 1.8.05 4. OP7 15(1) 1.8.05 5. OP7 15(2)(b) 1.8.05 6. 7. OP7 OP8 13(4)(c) 12(1)(a) 1.8.05 1.9.05 Page 22 Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 8. 9. OP8 OP9 17(1)(a)3 (3) (m) 13(2) 10. OP9 13(2) 11. OP9 13(2) 12. OP9 13(2) 13. OP9 13(2) 14. OP9 18(1)(c) (i) 12(4)(a) 15. OP10 16. OP10 12(4)(a) 17. OP12 16(2)(n) monitored on a monthly basis and the appropriate actions taken in the case of unexplained weight gain or loss. There must be nutritional and tissue viability assessments in place for all residents. The home must write a policy for the safe handling of medicines within the home and train staff to adhere to the policy The actual quantity of all medicines received into the home or returned to the pharmacy for destruction must be recorded. The home must see all prescriptions and install a system to check all the dispensed medicines and Medicines Administration Record (MAR) charts received into the home for accuracy. The home must safely store all medication and return and record all unwanted medicines to the pharmacy. The home must purchase a Controlled Drug cabinet that complies with the Misuse of Drugs (safe custody) 1973 The home must purchase a Controlled Drug cabinet that complies with the Misuse of Drugs (safe custody) 1973 The registered manager must provide adequate screening in shared rooms. (Previous timescale of 30.11.04 not met.) The registered manager must ensure that there are adequate and suitable locks on all toilets and bathrooms. The registered manager must consult residents about their social interests and make arrangements to engage in local, 1.8.05 1.8.05 1.8.05 1.8.05 20.5.05 20.6.05 19.8.05 1.8.05 1.8.05 1.8.05 Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 23 social and community activities. 18. OP15 12(3) The registered manager must ensure that residents choices and preferences in respect of food are provided for. Ways of promoting residents involvement and independence in the home must be explored and action taken to ensure this. (Not assessed for compliance during this inspection. Previous timescale given 30.11.04) Records of the food provided for residents must be kept in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual residents. The registered manager must ensure that food stocks are maintained at suitable levels. The registered manager must ensure that systems are in place to make residents aware of what meals are available. The registered manager must ensure that an appropriate complaints procedure is available to residents. The registered person must ensure that the garden area is made safe for the use of residents. The registered person must ensure that the bath seat is replaced. The registered manager must ensure that all areas used by residents have an emergency call system in place. The registered manager must ensure that the furniture in residents bedrooms is of a suitable standard. A plan for the 19.5.05 19. OP15 12(3) 1.8.05 20. OP15 17(2)4(13 ) 1.7.05 21. 22. OP15 OP15 12(1)(a) 12(1)(a) 1.7.05 1.7.05 23. OP16 22(1) 1.7.05 24. OP19 13(4)(b) 1.7.05 25. 26. OP21 OP22 23(2)(n) 23(2)(n) 1.8.05 1.9.05 27. OP24 16(2)(c) 1.7.08 Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 24 28. OP24 23(2)(p) 29. OP25 23(2)(p) 30. 31. 32. 33. OP26 OP26 OP26 OP26 13(3) 13(3) 23(2)(d)1 6(2)(k) 13(3) 34. OP26 13(3) 35. 36. 37. 38. OP26 OP26 OP26 OP26 13(3) 13(3) 13(3) 13(3) 39. 40. OP29 OP30 19 Sch 2 18(1)(c) (i) replacement of the furniture to be forwarded to the CSCI. Furniture provided in the home must be audited against the items listed within the standard and supplied. (Previous timescale of 30.11.04 not met.) The registered manager must ensure that there is adequate lighting in areas used by residents. (Bulbs replaced during the inspection.) Liquid soap and paper towels must be available in all bathrooms and toilets. Disposable gloves must be disposed of in clinical waste bags. All areas of the home must be kept clean, odour free and reasonably decorated. the organisation of the laundry must ensure that washed and unwashed laundry are kept separated. Evidence that the washing machine had a sluice cycle must be forwarded to the CSCI by 15.7.05. The broken floor tiles in the kitchen must be replaced. The tap must be replaced in the wash hand basin in the kitchen. All foods in the freezer must be dated when frozen. The registered manager must ensure that foods are probed and records kept to show that the required temperatures have been achieved. Staff recruitment records must evidence that all the appropriate checks have been undertaken. Staff must undertake training appropriate to meet the needs of the resident group. 1.8.05 19.5.05 19.5.05 19.5.05 1.8.05 1.7.05 15.7.05 1.8.05 1.7.05 1.7.05 1.7.05 1.7.05 1.9.05 Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 25 41. OP33 24 42. OP36 18(2) 43. OP37 17(2)4(17 ) 12(1)(a) 44. OP37 45. OP38 13(4) The home must develop a quality assurance tool, which takes into account the views of service users. (Previous timescale given 31.12.04. Not assessed for compliance during this inspection.) Staff must be supervised a minimum of 6 times a year. (Previous timescale of 30.11.05 not met.) The accident procedure must be amended to include the actions staff must take in the event of an accident in the home. The registered person must ensure staff have access to policies and procedures at all times. (Previous timescale given 10.9.04. Not assessed for compliance during this inspection.) Risk assessments are required for staffing. (Previous timescale given 30.11.04. Not assessed for compliance during this inspection.) The registered manager must ensure that Steradent tablets are kept locked away. The registered manager must ensure that all hot water temperatures are regulated to be delivered at a temperature between 42 and 44 degrees centigrade. The registered person must ensure that there are risk assessments in place for the premises, fire, staff and food. The registered manager must ensure that evidence that the 5 yearly electrical testing and portable appliance testing has 1.9.05 1.8.05 1.7.05 1.7.05 1.8.05 46. 47. OP38 OP38 13(4)(c) 13(4)(c) 19.5.05 1.6.05 48. OP38 13(4) 1.8.05 49. OP38 23(2)(c) 15.7.05 Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 26 50. 51. 52. 53. OP38 OP38 OP38 OP38 23(2)(c) 13(3) 23(2)(b) 13(4)(c) 54. OP38 13(4)(c) been carried out is forwarded to the CSCI. Evidence that the chair lift has been serviced must be forwarded to the CSCI. The registered manager must ensure that testing for Legionella is carried out regularly. Broken and missing toilet seats must be replaced. The registered person must ensure that staff and residents are not put at risk of slipping on the shower room floor. The registered manager must ensure that bedroom locks can be opened in an emergency. 1.7.05 1.8.05 15.7.05 1.8.05 1.8.05 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 OP28 OP31 Good Practice Recommendations 50 of all care staff employed by the home must possess NVQ level 2 or equivalent by 2005. The registered manager must achieve training in NVQ level 4 by 2005. Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Birmingham & 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 Dorcas House v228241 e54_s16840_dorcas_v228241_190505 ui - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!