Inspection on 22/07/05 for The Firs

This inspection was carried out on 22nd July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Firs 08/03/10

The Firs 24/11/09

The Firs 24/11/08

The Firs 12/08/07

The Firs 10/10/06

The Firs 01/12/05

The Firs 01/03/05

The Firs 18/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Firs and 16 Margaret Road 141 Malvern Road Worcester Worcestershire WR2 4LN Lead Inspector Andrew Spearing-Brown Unannounced 22 July 2005 10:00 am 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. The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Firs and 16 Margaret Road Address 141 Malvern Road, Worcester, Worcestershire WR2 4LN 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) 01905 426194 01905 426194 Eldahurst Limited Mrs Sandra Lynne Ghalamkari Care Home 19 Category(ies) of DE(E) Dementia over 65 (6) registration, with number OP Old age (19) of places PD(E) Physical disability over 65 (15) The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Firs may accommodate a maximum number of 15 people in categories OP and PD(E) and DE(E) 2. The Firs may only accommodate a maximum of 2 residents with a dementia type illness. 3. Maragret Road may not accommodate any person with a physical disability Date of last inspection 1 March 2005 Brief Description of the Service: The Firs provides board, accommodation and personal care for fifteen people over the age of sixty-five years with physical disabilities. The registered manager recently applied for a variation in the certificate of registration which was approved by the CSCI as detailed above. 16 Margaret Road is a separate semi-detached house that is divided from The Firs by their joint back gardens. The two properties are registered as one care home. This home is located in the St Johns area of Worcester. The two buildings are adapted and extended domestic dwellings providing four single bedrooms in Margaret Road and eleven single bedrooms and two double bedrooms in The Firs. There is one single room in The Firs that measures slightly less than ten square meters. All other bedrooms meet or exceed the National Minimum Standards. A shaft lift is provided in The Firs and a stair lift in Margaret Road.The registered proprietor is the company Eldahurst Limited. The responsible individual and the registered manager is Mrs Sandra Lynne Ghalamkari. A deputy manager Mrs Lynn Thomas supports the registered manager. The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over a period of two days totalling 7 ½ hours. The previous full inspection took place during early March 2005. A letter of serious concern was written immediately following the last inspection due to a number of concerns regarding medication and uncovered radiators and pipe work. The main focus of this inspection was therefore to assess the progress made in relation to the requirements from the last inspection. On the first day of this inspection the registered manager was present as was the deputy manager. The deputy manager was on duty during the second visit. Many areas of the home were seen including some bedrooms and all communal rooms. The care records of a small sample of residents were seen. Other documents seen included medication records and staff records. What the service does well: What has improved since the last inspection? The registered manager applied for a variation in registration categories albeit after changes took place in relation to Margaret Road. This change is now approved. No further changes are to take place without proper consultation with the CSCI. Night staffing levels have improved since the last inspection. Covers are now in place over radiators, exposed pipes however remain uncovered. The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 6 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. The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 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 The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 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) 2, 3 and 4. Standard 6 is not applicable to The Firs. Pre assessments carried out are not in sufficient detail to demonstrate that the home is able to meet care needs prior to their admission. In addition the lack of progress in providing a suitable statement of conditions and up to date training in dementia care leaves residents vulnerable. EVIDENCE: It was evidenced that pre assessments are carried out prior to residents moving in to the home. However the assessments carried out are not done in detail as this consists of a tick box system. Although an initial care plan was in place it would not of been possible to draw this up relying solely on the assessment. A copy of a blank statement of terms and conditions was seen. This did not cover areas as listed under standard 2 of the National Minimum Standards. Reference continues to be made to Worcester County Council as the registration authority; this function ceased on 1st April 2002 with the introduction of the National Care Standards Commission the forerunner to the CSCI. The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 9 The property on Margaret Road may now accommodate residents with a dementia type illness. It is therefore necessary for staff working in this home to receive appropriate training in dementia care. Training must therefore be arranged for staff who have not received this in the past with suitable refresher training for others. The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 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) 9 The systems for the administration of medication continue to be poor and potentially place residents at risk EVIDENCE: At the time of the last inspection during March 2005 serious concerns were expressed in relation to a range of matters regarding the administration, safe storage and recording of medication. These concerns were in addition to the concerns raised during an inspection in June 2004. Unfortunately little progress was seen during this visit. The registered manager was informed that the CSCI will consider enforcement action if suitable improvement is not achieved. Shortfalls identified included evidence that medication was not given as prescribed while audits of other medication did not balance including courses of antibiotics. A carer was observed removing medication from a trolley which is unsuitable for use and taking to a resident without referring to the medication administration record (MAR) sheet and leaving the remaining medication unsecured. Gaps were noted upon the MAR sheets whereby medication was either not signed as given or no reason was given for why it was omitted. The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 11 On one occasion the MAR sheet was signed on the wrong date. Some medication was not signed in as required. The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 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 Social activities are organised, creative and provide some areas of stimulation and interest for residents living in the home. EVIDENCE: On one of the days between the two inspection days the majority of residents had a day out at Weston Super Mare. Plans were in hand for a forthcoming river trip, which was to include tea. During the inspection, which was unannounced, an organist arrived to play music in the large lounge. The organist confirmed that he had visited the home a number of times. Residents were also having their hair done in one of the smaller lounges, which also doubles up as the smoking lounge. The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 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) None of the standards in this section were assessed in any detail as part of this inspection. As a result these standards will be assessed as part of a forthcoming inspection at The Firs. EVIDENCE: The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 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) 19, 20, 21, 23, 25 and 26 The home overall is comfortable and clean. Improvements are need in relation to ensuring hygiene by means of the provision of equipment to ensure residents live in a hygienic environment. EVIDENCE: This inspection took place during a very warm period of weather; therefore areas such as lighting and heating were not accessed. Following the previous inspection radiator covers were fitted to a number of radiators. Pipes also identified as ‘significantly hot’ remain exposed; suitable action needs to be take place without delay. Several residents’ bedrooms were viewed. All those seen demonstrated that residents are able to bring personal belongings into the home with them. As part of a recent variation in registration a change to the layout of the ground floor at Margaret Road was approved. In the event of any further changes approval must be sought from the CSCI prior to the change taking place. The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 15 A door handle in Margaret Road property had a screw protruding from it, which could cause injury. The Firs has a lounge, a parlour and a dining room. The dining room is situated within the conservatory, which can get hot at times. The registered manager has in the past explored replacing the roof with a more conventional type however this has not taken place. The home was clean and sufficiently tidy. No offensive odours were noted. The washing machine does not have a sluice facility to ensure that disinfecting of any soiled laundry takes place. Antibacterial soap was in place at a wash hand basin near to the kitchen but not elsewhere such as areas where staff should be able to wash their hands. The washing machine is place was reported to remain the same as highlighted in previous reports in that it does not have a sluice facility. The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 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 Procedures for the recruitment of staff are not sufficiently robust to ensure the protection of residents. Although staffing levels are maintained the level of training input needs to be improved. EVIDENCE: The staff files for two newer members of staff were viewed these indicated that the registered manager had not undertaken all the necessary recruitment checks to ensure the protection of residents. The manager was not aware of the POVA procedures (Protection of Vulnerable Adults) under which employers are required to apply for a POVA 1st check on all newly appointed staff who have take up post since 26th July 2004. An immediate requirement notice was issued in relation to obtaining suitable written references and a satisfactory check from the Criminal Records Bureau including a check against the Protection of Vulnerable Adults register. An employee who was previously too young to undertake care work and therefore worked as a domestic has now moved over to care having passed her 18th birthday. No domestic staff are now employed and therefore care staff are required to carry out this role. Six members of care staff currently hold an NVQ level 2 qualification while another member of staff continues to undertake this training. This equates to having 25 of staff qualified. The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 17 The registered manager has recently reviewed and increased the staffing levels deployed between the two properties during the night shift. Excessive working hours noted at the last inspection are no longer taking place, the registered manager needs to continue to monitor that this does not reoccur in the future. The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 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 Effective and appropriate quality monitoring and staff supervision needs to be developed and introduced; furthermore shortfalls in staff training were identified. Shortfalls in the routine testing and checking of fire safety equipment and some lifting equipment as well as some health and safety practices also potentially place residents at risk. EVIDENCE: No formal supervision of care staff takes place in line with the relevant standard. No quality assurance programmes are in place although the home has taken part in Worcester County Councils ‘Having Your Say’ project whereby some advocates visited the home. Financial and business plans were not sought on this occasion. No cash is held on behalf of residents, any expenditure accorded such as hairdressing is invoiced to the resident’s representative. The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 19 No certificates or other documentation was available to indicate that the stair lift in Margaret Road had been serviced. The hoists over baths have not received a service in line with Lifting Operations and Lifting Equipment Regulations 1998. An immediate requirement notice was issued in relation to these matters. Records were in place in relation to the passenger shaft lift. Shortfalls in a number of heath and safety records were identified in addition to those highlighted elsewhere such as medication records. Mandatory training has not taken place for all members of staff in relation to moving and handling, first aid, fire safety and basic food hygiene. Training dates for forthcoming events were available. A number of concerns were highlighted in relation to fire safety records. The weekly testing of the fire alarm was recorded as taking place at the end of June 2005; therefore a gap of three weeks. The visual checking of the fire extinguishers, emergency lighting and self-closing doors had happened on the 1st June 2005; no record of the 1st July existed. Shortfalls were also found in relation to the servicing of the fire alarm and fire extinguishers both of which had not happened for in excess of 12 months. No fire risk assessment is in place. Fire doors noted as propped open during the last inspection were again held open by means of wooden wedges. These doors included the kitchen door, which is a high risk area. The serving hatch doors, which include fire safety glass, were open while cooking was taking place therefore giving direct access into the dining room. Some new chairs are in place within the main lounge, which comply with The Furniture and Furnishing (Fire) (Safety) Regulations 1988 (as amended in 1989 and 1993). Any other chairs that do not meet these regulations such as chairs belonging to the home located in residents’ bedrooms also need replacing. A certificate regarding the required testing of gas equipment was seen; it was believed that this was dated September 2004 and therefore still in date. The registered manager needs to ensure that future tests include as equipment, appliances together with pipe work and flues. No records were available to demonstrate that the registered manager has in place suitable systems to ensure the safety of portable electrical appliances. The hard wiring was last tested 5 years ago and therefore is now in need of a routine check. Temperature records were viewed; these showed that one fridge is constantly operating at a level that is too high. This fridge did only contain low risk items however it was also noted that the casing and seal to this piece of equipment were damaged which would prevent suitable cleaning taking place. Therefore this item must be replaced. Since the last inspection a fly screen has been fitted to the outside door, however this was tied back and therefore ineffective. The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 20 The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.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 x 1 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 2 2 x 3 x 2 2 STAFFING Standard No Score 27 3 28 2 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 1 x 3 1 1 1 The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 Requirement The Statement of Purpose must be amended so that it includes all the information detailed in Regulation 4 and Schedule 1. Copies must be made available to the Commission for Social Care Inspection and available in the home to any service user or their representative. (Previously Part met – not assessed as part of this inspection - timescale extended.) 2. 1 5 A Service User’s Guide, which includes all information detailed in Regulation 5 and Standard 1, must be available in the home and copies must be given to the Commission for social Care Inspection, all current, and any prospective, service users. (Previously Part met – not assessed as part of this inspection - timescale extended.) 30/09/05 Timescale for action 30/09/05 The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 23 3. 2 5 The statement of terms and conditions must be amended so that it includes all the information detailed in Standard 2.2. Each service user must be provided with a copy at the time they move into the home. (Previous timescale of 31/05/05 not met). 30/09/05 4. 7 15 The registered person must ensure that service user plans cover all aspects of care as set out in Standards 7 and 3. (This standard was not fully assessed as part of the inspection carried out on 22nd July 2005. The timeframe previously set remains - this requirement will therefore be reassessed as part of a future inspection). 30/04/05 5. 9 13 (2) The registered manager must ensure that medication administration records are completed adequately and at the time of administration. (Previous timescale of immediate and on going not met). immediate and on going 6. 9 13 (2) The registered person must ensure that a record is maintained of all medication received into the home. (Previous timescale of immediate and on going not met). immediate and on going The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 24 7. 9 13 (2) The registered manager must ensure that medication is held securley at all times. A sluicing facility must be provided. (Previous timescale of 31/05/05 not met). immediate and on going 31/12/05 8. 21 26 13 16 9. 25 13 (4) The registered manager must ensure that risk assessments are carried out on all the identified radiators and pipes. Appropriate action must be taken to either eradicate or reduce the risk of scaling. Risk assessments must also be carried out on any other radiators and / or pipes that although not identified by the inspector pose a similar risk. (Part met - radiators now covered, exposed pipes remain uncovered) 31/10/05 10. 26 13 (3) The registered manager must ensure that suitable facilities are available to prevent the risk of cross infection such as antibacterial soap (Previous timescale of 31/03/05 not met). 31/08/05 11. 29 19 Recruitment procedures must be developed and implemented in accordance with the requirements of Regulation 19, Schedule 2 and Standard 29. (Previous timescale of 31/03/05 not met). immediate and on going The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 25 12. 29 17 Staff records must be maintained immediate in accordance with regulation 17 and on (2) and Schedules 2 and 4 going (Previous timescale of 31/03/05 not met). 13. 33 24 A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 31/05/05 not met). 31/10/05 14. 36 18 All members of staff must receive formal supervision that includes all aspects of practice, philosophy of care in the home and career development needs at least 6 times a year. (Previous timescale of 31/05/05 not met). 30/09/05 15. 37 17 Records must be maintained in accordance with Regulations 4,7,9,17,19 and Schedules 1,2,3,4. (Previous timescale of 31/05/05 not met). 31/10/05 or earlier as set elsewhere 16. 38 13 Risk assessments must be carried out and recorded for all the safe working practices topics covered in Standards 38.2 and 38.3 (This standard was not fully assessed as part of the inspection carried out on 22nd July 2005. The timeframe previously set remains - this requirement will therefore be reassessed as part of a future inspection). 30/04/05 The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 26 17. 38 23 (4) The registered manager must make suitable arrangements to ensure that fire doors do not have to be propped open to afford service users ease of passage. (Previous timescale of 30/04/05 not met). immediate and on going action to find a suitable alternative 18. 38 13 (4) The registered manager must make suitable arrangements to prevent flying insects gaining access to the kitchen. (Previous timescale of 30/04/05 not fully met). immediate and on going 19. 38 13 The registered manager must ensure that adequate temperature records regarding ‘fridge, freezer and hot food at the point of serving are maintained within the kitchen. (Previous timescale of immediate and on going part met). 31/08/05 to replace equipment 20. 38 13 (4) (5) 23 (4) (b) The registered manager must ensure that all staff attend mandatory training. (Previous timescale of 31/05/05 not met). 31/10/05 21. 38 23 The registered manager must ensure that all soft furniture such as chairs provided by the home meet The Furniture and Furnishing (Fire) (Safety) Regulations 1988 (as amended in 1989 and 1993). (Part met) 31/12/05 to replace remaining furniture The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 27 22. 38 13 The registered manager must immediate ensure that suitable documents and on are available to demonstrate that going the stair lift is maintained and serviced as required. The registered manager must ensure that suitable servicing and maintenance of bath hoists takes place as required. The registered manager must ensure that the weekly and monthly in house fire and emergency lighting tests are carried out and suitably recorded. The registered manager must ensure that the servicing of the fire extinguishers and fire alarm is carried out as required and suitably recorded. The hatch between the kitchen and dining room must remain closed when not in operation for serving meals especially while cooking duties are undertaken. The registered manager must ensure that suitable arrangements are in place to ensure the safe working order of portable electrical appliances. immediate and on going 23. 38 13 24. 38 23 (4) (c) immediate and on going 25. 38 23 (4) (c) immediate and on going 26. 38 23 (4) (a) immediate and on going 27. 38 13 (4) immediate and on going 28. The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 28 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 9 19 25 Good Practice Recommendations The medication trolley should be replace by one more suitable to the needs of the home. A programme of routine maintenance and renewal of fabric and decoration should be produced and implemented. (Not assessed on this occasion) A monitoring system should be implemented to ensure water temperature valves are working efficiently and risks from Legionella bacteria are addressed. (Not assessed on this occasion) The registered manager should prepare an action plan which will enable a minimum of 50 of the care staff to attain a qualification at NVQ level 2 or equivalent by 2005. A business or financial plan should be available for the establishment that is open to inspection and reviewed annually. (Not assessed on this occasion) 4. 28 5. 37 The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 29 Commission for Social Care Inspection The Coach House, John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Firs and 16 Margaret Road E52 S18684 The Firs (16 Margaret Rd) V240218 220705.doc Version 1.40 Page 30 - 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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