Inspection on 27/09/05 for Greenauns

This inspection was carried out on 27th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Greenauns 21/04/08

Greenauns 12/06/07

Greenauns 01/06/06

Greenauns 08/03/06

Greenauns 29/11/04

Greenauns 13/07/04

Greenauns 09/03/04

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

CARE HOMES FOR OLDER PEOPLE Greenauns 81 Fountain Road Edgbaston Birmingham West Midlands B17 8NP Lead Inspector Kulwant Ghuman Unannounced Inspection 27th September 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Greenauns Address 81 Fountain Road Edgbaston Birmingham West Midlands B17 8NP 0121 420 3361 0121 420 3361 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Mary Loftus Mr James Patrick Loftus Mrs Mary Loftus Care Home 8 Category(ies) of Old age, not falling within any other category registration, with number (8) of places Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29 November 2004 Brief Description of the Service: Greenauns is a small family run home for eight older people situated in a residential area of Edgbaston. The home is a five- minute walk from the main Hagley Road, from which one can travel into Birmingham by bus in one direction. In the other direction one can travel to Kidderminster and access the M5 motorway. The home is registered to care for older people who are frail and require 24hour care, excluding people in need of care for reasons of dementia, learning disability and other categories. It provides a homely environment for care with consistent carers. It has two double bedrooms and four single rooms decorated in individual style and with people’s personal belongings evident. All of the bedrooms have an en-suite toilet facility. The home has a lounge/dining area which leads on to a small conservatory. The conservatory overlooks the garden. The garden is flat and can be accessed easily by the residents. The home has an assisted bathroom on the ground floor. There is a stair lift up to the first floor. The home offers a variety of activities that the service users can choose to participate in, both within the home, and occasional short trips out. Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over part of a day during September 2005 by one inspector. This was the first of the two statutory visits for 2005/2006. There were five residents in the home at the time of the inspection. The inspector was able to tour the building, speak with the residents and sample some records. What the service does well: 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. Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Residents and their representatives had access to good information about the home and the facilities provided. Some small additions needed to be made to it to make it fully comprehensive. The home was able to meet the needs of the residents but full information about their needs must be obtained before any admissions are made to the home to ensure that only residents whose needs could be met by the home were admitted. EVIDENCE: There was a document in place that doubled up as the statement of purpose and service user guide. The statement of purpose needed to make it clear that the home was registered to take people over 65 years of age but not if they had dementia. The complaints procedure needed to be amended so that it showed the timescales within which any complaint should be investigated and that a complaint could be referred to the Commission for Social Care Inspection (CSCI) at any time and that complainants did not have to wait until the home had investigated it. The statement of purpose did not give the actual room sizes in the home but including a very nice description of each bedroom showing what was included in them. The document needed to Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 8 include an up to date inspection report on the home, an overview of complaints made regarding the service and any views of the residents. Neither of the two residents’ files sampled contained a contract or statement of terms and conditions on them. There was a contract available in the home that would be appropriate with the addition of the room to be occupied by the resident recorded on it. Some information about the needs of the most recent admission to the home had been provided by the hospital and the inspector was told by the resident that a visit was made to the home prior to admission to the home, however, no record was kept of this visit and there was no record of the assessment carried out by the home to ensure that the resident’s needs could be met by them. The manager needed to ensure that they obtained a full assessment carried out by the placing authority, or a full assessment needed to be carried out by the home before any residents were admitted to the home. There was a resident who was outside of the home’s registration category and the home needed to make an application for variation for the individual. The home was able to meet the needs of the residents in a homely environment. There were some adaptations to the home such as call system, chair lift and grab rails. Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9, 10 Care plans were very well structured and gave staff adequate information on how to meet the residents’ needs. Some risk assessments needed to be further developed to safeguard both staff and residents. The health care needs of residents were being met. EVIDENCE: The files of two residents were sampled. It was pleasing to see that there were care plans in place for all residents. Care plans were personalised, detailing the resident’s preferences and self care abilities and reviews were being undertaken on a monthly basis. The home had started the process of including residents and their representatives in the reviews of care plans. There were manual handling assessments in place however, they were not dated and did not give sufficient detail on how staff were to undertake transfers. The staff needed to have training in manual handling assessment so that their knowledge and skills could be updated. Personal risk assessments needed to be put in place for residents indicating any risks and strategies for managing them, for example, residents who were losing weight or who were at risk of falling. The risk assessments needed to include what actions staff would take in the event of a fall. Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 10 Daily reports were not being written about the residents. It was important to ensure that these were undertaken so that an overview of the residents lives was recorded and the daily reports could be used when undertaking monthly reviews and overall view of any improvements or deteriorations in the residents was available. This could then be used to guide any changes in the resident’s care plan and ensure that the resident’s needs continued to be met. The health care needs of residents were being met. There was evidence in the home that assessments were being carried out by other professionals, for example, the continence advisor and one of the residents said that the optician was to be seen regarding his spectacles. The visits by health care professionals were being recorded in a communal diary. It was recommended that a sheet was set up in the residents’ files that could be used to record the visits made by other professionals, the reason for the visit and the outcome. On the files sampled there were no tissue viability assessments in place, even though in one case the individual was at risk of developing pressure sores. Plans had been put in place and specialist cushions and mattress were in use. The care plan indicated that the individual was to be turned regularly at night. It was pleasing to note that the home had significantly improved the management of medicines. There was a monitored dosage system in place for most medicines. The supplying pharmacist was carrying out inspections on a regular basis. None of the residents were managing their own medicines. There were no controlled medicines in the home. There was an agreement with the supplying pharmacist that a controlled medicines register would be provided if the need arose. There was a self medication and homely remedies policy in the home. Agreement needed to be sought from the GP for the use of the homely remedies for the residents. On checking the medicines in the home a discrepancy was found with the Paracetemol tablets. Some tablets had been signed as given but were not given. A copy of the recent prescription needed to be kept with the MAR charts so that the medicines dispensed by the pharmacy could be checked against the prescription. There were screens available in double bedrooms although none of the bedrooms were doubly occupied at the time of the inspection. There were privacy locks on toilets and bathrooms. Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 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 the following standard(s): 13, 14, 15 Residents were able to maintain contact with friends and relatives and exercise choice over their daily living. The residents said they were happy with the food provided. EVIDENCE: Residents were able to watch films and play board games. There had not been any trips out of the home. The inspector was told that the residents were not able or did not wish to go out. Residents were able to have visitors at all reasonable times and this was referred to in the service user guide. Residents were able to exercise choice by choosing the clothes they wore, the times of rising and going to bed and the food they ate. The residents said they had enjoyed the main meal of the day and one said that ‘they did rather well for food’ and explained about the availability of food throughout the day. Drinks were provided on a regular basis in the home. The dining area was pleasant and the meal time unhurried with choices being offered to the residents. There were no set menus in the home and residents were asked what they wanted to eat on a daily basis. The home were not recording daily food intake Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 12 by residents. There were some residents who were unable to be weighed, as they could not stand on the weighing scales. One resident had been admitted to hospital as she had not been eating well and this was thought to be due a mental health issue. She had been referred to a dietician at the hospital. Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 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 the following standard(s): 16, 18 The complaints procedure needed to be amended to ensure that complainants were clear of the process and an adult protection procedure was needed for the home so that staff knew what their responsibilities were if any concerns were raised. EVIDENCE: There was a complaints procedure in the home but it needed to be amended to give an indication of timescales within which any complaint would be addressed by the home and to make it clear to any complainant that a complaint could be referred to the CSCI at any point of the procedure. Three complaints had been logged in the home and they had been appropriately managed by the home. No complaints had been lodged with CSCI regarding the home. The home did have a copy of the Local Authority’s multi-agency guidelines on adult protection however the home needed a procedure of actions that staff would need to undertake in the event of any allegation or suspicion of abuse. A whistle blowing procedure needed to be in place. The majority of the staff group in the home were related and although this can be positive in terms of close working and managing the rotas this could also pose barriers to individuals being able to raise concerns about the home or any adult protection issues. The home needed to look at ways in which any complaints regarding the home or any adult protection issues could be referred Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 14 to other agencies if the complainant or whistle blower felt that they could not raise it directly within the home. Criminal record bureau checks for all staff had been undertaken. Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26 Care was provided in a homely environment. Residents were happy with their bedrooms. Some improvements were needed to improve privacy in bedrooms with the fitting of appropriate locks. EVIDENCE: The home can accommodate residents with poor mobility to the bedrooms on the ground floor however, as stated in the service user guide bedrooms on the first floor are not suited to those with limited mobility. Greenauns is a family run home and provides care in a family environment. The furnishings in the lounge and conservatory were domestic in character and of good quality. The home had a no smoking policy. The dining area was sited at the end of the lounge and has enough space for the service users to be seated comfortably together. There was however, limited wheelchair access. The home needed to consider in relation to their statement of purpose whether they could provide a service for people who use wheelchairs inside the premises. Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 16 Greenauns had en-suite toilet facilities in each bedroom, some of these were quite small and this may become an issue, as residents need more assistance with mobility. There was only one communal toilet facility close to the lounge and this was within the assisted bathing facility, but was not inspected during this inspection. There was a stair lift available in the home but there was a step at the top of the stairs that residents needed to be able to climb. There were two emergency call systems in place in the home. One was a door bell by the bed and the other system has been recently fitted. One of the call points tested during the inspection did not alarm and the inspector was told that it might need a new battery. The manager must ensure that the system was serviced and that there was a system in place for testing the batteries on a weekly basis. There were grab rails in place in the corridors. The bedrooms appeared to meet the needs of the residents in the home and were personalised to the residents’ liking. Locks were not available on all bedroom doors. There was central heating available in the home. All the radiators had been guarded and the hot water tested in one bedroom and the shower over the bath on the first floor were at an appropriate temperature. The windows openings were appropriately restricted. The home was found to be clean and odour free. Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 There was a very small staff team that worked in the home and the shifts were covered by agreement but there was no rota in place. Some staff appeared to work long hours putting the health and safety of staff and residents at risk. All staff need to have undertaken mandatory training to ensure they have the skills and knowledge to undertake their roles. EVIDENCE: There was no rota available in the home. At the time of the inspector’s arrival there were three staff in the home. In addition to the family members there was one additional member of staff. Hours that staff worked were recorded in a daily dairy. Examination of this diary showed that on occasion’s staff worked excessively long hours for example, from 11am to 9pm and then a waking night shift. This was not acceptable as the health and safety of both staff and residents could not be guaranteed. Two of the family members had undertaken training up to NVQ Level 3 in addition to the care manager who was a qualified nurse. There had been no new staff employed at the home since the last inspection. All existing staff had CRB forms in place. Certificates of training undertaken by two of the staff were seen. There were no individual contracts of employment or job descriptions in place, or evidence of proof of identity but as they were family members this was not relevant except for one member of staff. Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 18 Two of the staff had undertaken medicines management training during 2005 but it was not clear whether this was accredited training. The registered person must undertake training analysis need assessments for all staff and ensure that all staff have undertaken mandatory training including manual handling, first aid, infection control, food hygiene and fire training. Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38 The care of residents was managed well. There was a need for the development of documents in the home and the future management of the home decided upon. EVIDENCE: The current manager of the home was a registered nurse however the inspector was informed that she had not maintained a live registration and had decided that she was not going to undertake the Registered Managers Award. There was no evidence to show that she had undertaken any training to update her knowledge. Plans for the future of the home were unclear as no one individual had decided to take on the management of the home. Further discussions with the owners will need to take place to determine the future management of the home. As the majority of the staff were family members they meet on a regular basis but did not record any of their discussions or conversations with the residents. Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 20 It was recommended that records of these informal meetings were kept. There was no formal supervision for any of the staff. As the majority of staff were close family members it is advised that an external contact is identified in the complaint and adult protection procedures to make it easier to raise concerns about the home. There was no formal quality assurance system in place. The inspector was advised that the home did not hold the personal allowance for any residents. The registered manager had delegated the responsibility for policy development and management of the records to a member of staff who had worked hard to update some of the documentation however there was a substantial amount of work outstanding. Fire tests were carried out on a regular basis to maintain fire safety in the home. The servicing of the fire alarm system, the gas equipment and portable electrical appliances was out of date. The fire risk assessment needed to be further developed and the home was advised to access the fire risk assessment forms from the West Midlands Fire Service website. A COSHH folder was in place and accident records were appropriately completed and stored. The Environmental Health Officer had recently inspected the kitchen and there were no outstanding requirements. Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 2 3 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 2 2 X 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 X 3 1 2 2 Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement The statement of purpose must include all the information required in Schedule 2 of the Care Homes Regulations, including bedroom sizes and the needs of residents that can be met in the home. An application for variation must be submitted for the service user under 65 years of age. The service user guide must include a current inspection report, an overview of complaints and service user views about the home. The resident’s contract of terms and conditions must include the room number to be occupied. (Previous timescale of 30/04.05 not met.) All residents must be provided with a copy of the terms and conditions of residence at the home. The registered person must devise and implement a formal pre admission assessment document. (Previous timescale of 30/04/05 not met.) DS0000016770.V254416.R01.S.doc Timescale for action 1 OP1 4(1)(c) 01/11/05 2 OP3 4(3)(b) 01/11/05 3 OP1 5 01/11/05 4 OP2 5(1)(b) 01/11/05 5 OP2 5(1)(b) 14/11/05 6 OP3 14(1)(a) 01/12/05 Greenauns Version 5.0 Page 23 7 OP3 14(1)(b) 8 OP7 13(5) 9 OP7 13(4)(c) 10 OP7 12(1)(a) 11 OP8 12(1)(a) 17(1)(a) Sch3(3) (m) 12 OP8 The manager must ensure that a copy of the assessment carried out by the placing authority is obtained by the home or a comprehensive assessment is carried out by the home prior to admission. Manual handling assessments must give sufficient detail on how staff are to undertake transfers and must be dated and signed on implementation and at each review. A personal risk assessment must be in place for all residents with strategies for managing the risks. A daily report in respect of each resident must be written. (Previous timescale of 30/11/04 not met.) Records made by health care professionals must be recorded in the residents file and not in a communal diary. There must be a tissue viability assessment in place and a plan for managing any identified needs. A copy of the prescription must be kept with the MAR charts to enable medicines to be checked when received from the pharmacy. The manager must ensure that medicines are given to residents and as recorded on the MAR charts. Agreement must be arranged from the residents’ GPs to allow the home to administer homely remedies. The home must maintain a record of food provided for each resident. (Previous timescale of 30/04/05 not met.) DS0000016770.V254416.R01.S.doc 14/11/05 14/11/05 14/11/05 14/11/05 14/11/05 14/11/05 13 OP9 13(2) 14/11/05 14 OP15 17(2) Sch 4(13) 14/11/05 Greenauns Version 5.0 Page 24 15 OP16 22 The complaints procedure requires further development to include the information that the complainant can consult CSCI at any stage in the process. The home is required to ensure that all residents and/or their representatives receive a copy of the updated complaints policy. (Previous timescale of 30/04/05 not met.) The complaints procedure must give timescales within which a complaint will be addressed. There must be a policy and procedure for staff to follow in the event of a suspicion or incident of abuse, including the whistle blowing procedure. (Previous timescale of 31/05/05 not met.) All staff must undertake training in adult protection and whistle blowing. (Previous timescale of 31/05/05 not met.) All call points must be maintained in working order and the call system must be serviced on a regular basis. To ensure privacy and dignity, locks must be fitted on residents’ bedroom doors. These should enable residents to have a key but not to be locked in. They should be able to be overridden in an emergency. A programme for installation needs to be devised and submitted to CSCI. (Previous timescale of 14/07/05 not met.) A staffing rota must be on display at the home that is a DS0000016770.V254416.R01.S.doc 01/12/05 16 OP16 22 01/12/05 17 OP18 13(6) 01/12/05 18 OP18 13(6) 01/02/05 19 OP22 23(2)(c) 01/11/05 20 OP24 12(4) 01/11/05 21 OP27 17(2) Sch 4(7) 01/11/05 Greenauns Version 5.0 Page 25 true reflection of the hours that each staff member has worked. (Previous timescale of 29/11/04 not met.) All future staff must be subject to a rigorous recruitment procedure. (Previous timescale of 10/03/04 not met.) Files for existing staff must be set up to meet the requirements detailed in schedules 2 and 4. This must include evidence proof of identity and copies of training and qualification certificates. (Previous timescale of 09/05/04 not met.) The registered person must devise and issue job descriptions in respect of all staff. (Previous timescale of 30/12/04 not met.) The registered person must undertake training analysis need assessments for all staff. (Previous timescale of 31/05/05 not met.) The home must implement a Quality Assurance programme that has a regard to comments and complaints from the service users, their families and staff and the results must be included in a business plan for the forthcoming year. (Previous timescale of 30/06/05 not met.) Care staff must receive supervision six times a year and supervision should cover all areas of practice, philosophy of care and career development. A written record of this must be maintained. The registered person must DS0000016770.V254416.R01.S.doc 22 OP29 19 Sch2 01/01/06 23 OP29 19 Sch2 01/11/05 24 OP30 18(1)(c) (i) 01/12/05 25 OP33 24 01/02/06 26 OP36 18(2) 01/01/06 27 OP37 17 01/02/06 Version 5.0 Page 26 Greenauns ensure that all the records required by Schedules 1, 2, 3, and 4 are maintained in the home. 28 29 30 OP38 OP38 OP38 23(4)(c) (iv) 23(2)(c) 23(2)(c) The fire alarm system must be serviced. Portables appliances must be checked. The gas equipment must be serviced. The new nurse call system must be serviced and the batteries checked on a regular basis. 10/10/05 17/10/05 10/10/05 31 OP38 23(2)(c) 17/10/05 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 3 4 5 6 Refer to Standard OP7 OP8 OP31 OP32 OP34 OP38 Good Practice Recommendations It is recommended that the moving and handling risk assessment is further developed to include the action to be taken in the event of a service user falling. A separate sheet should be set up in the residents’ files to record health care professionals visits, the reason for the visit and the outcome of the visit. An external contact should be identified in the complaint and adult protection procedures to enable concerns to be raised if it concerns an employee of the home. The registered person must record the minutes of all service user and staff meetings. It is recommended that the home have its accounting records available at the home. The home should access the fire risk assessment from West Midlands Fire Service. Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Greenauns DS0000016770.V254416.R01.S.doc Version 5.0 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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