Inspection on 08/03/06 for Greenauns

This inspection was carried out on 8th March 2006.

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 27/09/05

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 8th March 2006 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.V286043.R01.S.doc Version 5.1 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.V286043.R01.S.doc Version 5.1 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.V286043.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 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 a bathroom on the ground floor that allows for a limited amount of assistance. There is a stair lift up to the first floor. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this unannounced inspection over part of a day in March 2005. This was the second of the two statutory inspections for 2005/2006. To get a full picture of the way in which the home is running this report should be read in conjunction the inspection of 27th September 2005. At the time of the inspection there were 5 residents in the home. The inspectors spoke with one of the senior staff, 4 of the residents, examined some care documents and toured the building. The manager was unavailable due to ill health. What the service does well: What has improved since the last inspection? What they could do better: Although very good reviews of the residents needs were being carried out on a monthly basis the changes noted in the reviews were not always being transferred to the residents care plan. Staff needed to update mandatory training in moving and handling, first aid, infection control, food hygiene and fire safety to ensure the safety and well being of the residents. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 Page 6 Some of the requirements made at the previous inspection had been complied with whilst others remained outstanding and they needed to be complied with. Bedrooms that were currently vacant needed to have a suitable lock fitted before being used to accommodate any other residents so that the choice as to whether or not to lock the bedroom was available to the resident. The staff needed to ensure that residents outside the home’s category of registration were not admitted to the home, for example, residents with a diagnosis of dementia and under 65 years of age. The home needed to forward an application for variation for the residents outside of the home’s registration category. 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.V286043.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 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 the following standard(s): 1,2,3 and 5 There was some very good information available to prospective residents and their representatives to assist them on whether to move into the home. This could be further improved with the information identified. All residents needed to be given a contract to enable them to know what the terms and conditions of residence in the home were. Residents were assessed prior to admission to the home to ensure that their needs could be met. The home did not always comply with their conditions of registration. EVIDENCE: The statement of purpose and service user guide had been updated to include the size of bedrooms however it still stated that residents with dementia could be admitted to the home which was not in line with the home’s registration category. The complaints procedure within the service user guide needed to be amended to include timescales within which any complaint would be investigated and that the complainant could refer the complaint to the CSCI at any point of the process. An overview of the complaints received about the service and any views expressed by the residents or their representatives about the home needed to be included in the service user guide. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 Page 9 There were contracts available in the home; however, the residents or their representatives had not signed them. There was a pre-admission assessment in place that covered all the required areas ensuring that the home could meet the resident’s needs. The hospital discharge information for one of the residents clearly identified that the individual had been diagnosed as having dementia which was outside the homes category. The home needed to apply for a variation to admit a resident outside their category if they felt that the individuals needs could be met by the home before the resident was admitted to the home. The social workers care plan did not include any specific details. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9 and 10 Care plans included a great amount of detail to assist staff to meet the residents’ needs whilst enabling some independence for the residents. Risk assessments needed to be further developed to safeguard both staff and residents. The health care needs of residents were being met. The management of medicines in the home was good ensuring that residents received their medication in a timely manner. EVIDENCE: Four residents’ files were examined and all were found to have care plans in place. The care plans included very good details of what the needs of the residents were, how they were to be assisted and what self-caring abilities they had. The care plans were being reviewed on a monthly basis and it was pleasing to see the level of detail included in the reviews. The home was to be commended on the information included in the care plans and reviews. The staff needed to ensure that where the monthly reviews identified changes in the needs of the residents these were reflected in the care plans. There was a risk that staff would overlook the information in the reviews as they were superseded by the following reviews if the information was not transferred to the care plans. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 Page 11 Although the home was identifying the risks for the residents and the reviews identified how these were to be managed there were no clear risk assessments that identified the plan of how the risks were to be managed. There needed to be waterlow, nutritional and moving and handling assessments for all residents. The moving and handling assessments needed to include specific details on how staff were to assist a resident off the floor following a fall. There was evidence that the health care needs of the residents were being met however, it was not always clear in the records the reason and outcomes of visits made by the GP or district nurses. The home had started to make a daily record for each resident however, these needed to be improved to give evidence of how the residents’ social care needs were being met and to ensure that the care plans were being followed. The staff must ensure that where it had been identified that residents needed to be weighed on a weekly basis by health professionals this was done. Where there was an identified unintentional weight loss or gain by residents’ advice needed to be sought from the GP or a dietician. The home continued to use a monitored dosage system for the management of medicines. The residents were not on large amounts of medicines and the supplying pharmacist visited on a regular basis providing a report on the systems. None of the residents were self-administering medicines and there were no controlled medicines in the home. At the time of the inspection there were no homely remedies in use. The recording on the MAR charts was very good with no gaps, appropriate use of codes and medicines were being booked in and checked with the prescriptions. Only one minor error was identified whereby the amount of paracetemol in use during the previous month had not been entered on the charts so that it was not possible to carry out an audit. There were privacy screens available in double bedrooms and there were privacy locks on toilets and bathrooms. All bedrooms had a piece of furniture that could be locked. The bedroom doors did not have the appropriate locks in place. The need to provide choice and privacy was discussed with the member of staff and it was agreed that the currently vacant bedrooms would have locks fitted before the rooms were occupied. The locks must be of a type that do not enable residents to be locked in bedrooms, that enable the resident to lock the door from inside and outside and that allows the staff entry in the event of an emergency. During the inspection residents’ were heard to be addressed as ‘good girl’. This is considered to be poor practice indicating a paternalistic service that does not afford residents with the respect they deserve. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 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 the following standard(s): 12,13,14 and 15 The home did not evidence that the social needs of the residents were being met. 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: There was little evidence in the home that showed that the residents’ recreational needs were being met. The statement of purpose indicated that there were some activities provided by the home but these could not be evidenced. Residents told the inspectors that they could determine the time that they got up and went to bed. The home was aware of the religious needs of the residents and facilitated these needs as required. There was regular contact with the residents’ families and one visitor was seen at the home during the inspection. The statement of purpose indicated that visitors were welcome at all reasonable times. Care plans indicated where residents were able to make choices for example, choosing their clothes. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 Page 13 The home needed to look into the involvement of advocates in the home where required. The menus and records of food eaten by the residents were well maintained and indicated that there was a varied and nutritious diet provided. Residents were assisted to eat where required. Residents’ weights were being monitored to ensure that they were receiving appropriate nutrition. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 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 the following standard(s): 16 and 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. As discussed at previous inspections, there was a need for a system to be identified where complaints or concerns could be raised outside the home due to the close nature of the staff in the home. The home did record any complaints made by residents or their representatives. The complaints seen at the home were about issues between the residents. The complaints were discussed with the residents and assurances given. No complaints had been lodged with the CSCI regarding the service. The home should set up a complaints log that is bound, and ensure complaints are numbered so that the loose sheets do not go astray. The adult protection policy needed to be amended to ensure that the staff were clear what actions they would need to take in the event of an allegation of abuse. The inspectors were informed that the home was in possession of the multi-agency guidelines. The home needed to be sure that the adult protection policy was not in conflict with the multi-agency guidelines. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 Page 15 The home had developed a whistle blowing policy but it did not make clear that any person identifying poor practice would be protected under the Public Information Disclosure Act. It needed to include details of people or organisations that could be contacted when making any disclosures. There had been no new staff employed at the home and criminal record bureau checks had been undertaken at the last inspection. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Care is provided in a homely environment. Some adaptations have been made to the home but the home remains suitable mainly for residents who have a high level of mobility and independence. EVIDENCE: Care is provided in a homely environment and the accommodation consists of a lounge/dining room, conservatory, kitchen, laundry and an assisted bath on the ground floor. The home was suited to individuals with a good degree of mobility but those accommodated on the first floor could access the rooms via a stair lift however, there was one step at the top of the stairs that needed to be negotiated by residents without a stair lift. There were two emergency call systems in place. On testing one of the call points it was evident that the alarm was working on the emergency setting only. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 Page 17 The second was a domestic doorbell that the inspectors were informed rang in the flat on the second floor. The call system needed to be serviced so that it would alarm at the first touch. There were grab rails in the corridors. The communal space was homely and domestic in character. There was a no smoking policy in the home. Residents’ bedrooms were provided on the first and ground floors and the owners and their family occupied the second floor. Furniture in the bedrooms included bed, wardrobe, bedside cabinet, chest of drawers, chair and secondary lighting. Shared bedrooms had privacy curtains and there were some personal belongings evident in them. All bedrooms had an en-suite facility consisting of a toilet and wash hand basin. Some of the en-suite facilities were quite small and assisting residents with very limited mobility was difficult and there was no emergency call system fitted in them. Bedroom doors did not have a suitable lock on them. Following discussions with the staff member it was determined that the empty rooms would be fitted with a suitable lock before it was re-occupied and that any rooms that became vacant would then have a lock fitted before being reoccupied. The inspectors were informed that the bathroom on the first floor was no longer in use. This room needed to be locked off and made inaccessible to the residents. The bathroom on the ground floor was small and although it had a chair lift it was only suitable for individuals with a good degree of mobility. The wooden bath seat needed to be taken out of use as it did not promote good infection control procedures. One of the residents was unable to have a bath and generally had a body wash in the bedroom. The hot water being delivered to the bath was found to be higher than 50 degrees although the hot water being delivered to the wash hand basin was found to be acceptable. The home was centrally heated and the radiators had been guarded. The window openings had been appropriately restricted. The home was found to be clean and odour free. The inspectors were informed that there was a contract for the disposal of clinical waste but this was not available at the time of inspection for examination. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 and 30 The staff team know the residents well and provide care based on their experiences. The staff have not undertaken on-going training to ensure that the care provided is based on good practice guidelines. EVIDENCE: The staff team consisted of the owners and three other employees, two of whom were family members. At the time of the inspection the proprietors were unavailable and one member of staff did not arrive at work until after lunch due to an illness in the family. This highlighted the problems that could arise due to the small staff team. The staff member identified that now that the decision had been made to continue providing a service at the home more staff would need to be employed. The home had set up a staff rota since the last inspection, which indicated the shifts to be undertaken. There was evidence that some shifts were lasting 14 hours. This was not good practice on a regular basis as the staff could become over-tired. The rotas also identified that there was one individual identified as being on night duty and one person who was on call during the night. All staff undertook a multi-task role including care, cooking, cleaning and laundry. The manager had not undertaken any recent training and had decided to hand over the management of the home to another family member. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 Page 19 There was little evidence of recent training by the other staff. Evidence of training undertaken by two members of staff was available and indicated that they had undertaken NVQ 3 training in 2001. The only training undertaken by them since that time was handling of medicines (although it could not be determined that this was accredited training) and one day of dementia care training. Mandatory training including fire safety, health and safety, first aid, infection control and basic food hygiene needed to be undertaken by all staff in the next three months. Moving and handling needed to be undertaken as soon as possible as staff were moving one resident in particular. The inspectors were informed that training had been provided by the manager but that she was not a trained trainer. Inspectors were concerned that they were not basing their practices on current good practice guidelines. The home needed to seek advice on equipment that could be used in the home so that staff did not undertake lifting of residents. Employment and training files needed to be set up for the other staff in the home. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 Page 20 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, 36, 37 and 38 The care of the residents was well managed however there was a need for leadership to ensure that the home was developed in line with regulations and standards to ensure that residents received a safe and continually improving service. EVIDENCE: Since the last inspection it had been decided by the owners that the home will continue to provide a service and that the management of the home would pass to one of their children. This was discussed at the time of the inspection with the prospective manager and an application for registration would be forwarded so that the registration process could be progressed. There were several requirements that remained outstanding from the previous inspection. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 Page 21 Mandatory training had not been undertaken and residents had been admitted to the home who were outside of the homes registration category. No application for variation was made as identified at the last inspection for the individual outside the home’s category. There was no quality assurance system in place. There was no formal supervision for the staff however the individuals had daily contact with each other. The home had started to make daily recordings about the care given to the residents although these were basic. The recordings needed to be expanded to give an overview of the residents’ lives at the home and ensure that visits by health professionals were cross-referenced. The home had not been sending the appropriate notifications when residents had passed on or where there had been significant incidents such as falls to the CSCI. Health and safety in the home were generally managed satisfactorily, however the inspectors noted that a liquid covered by COSHH legislation had not been locked away and the hot water delivered to the bath was not regulated to 43 degrees centigrade. There were records that indicated that the fire checks were being carried out and that equipment such as the bath chair, electrical wiring checks, portable appliance checks, stair lift, fire alarm system and fire extinguishers were being serviced. The evidence for the gas equipment service, nurse call service and waste disposal contract was not available at the time of the inspection. The accident records had been recorded and put onto the resident’s files. The records had not been appropriately numbered and there was no system in place for the inspectors or the manager to be able to audit the accident forms and look for any patterns. It was advised that a copy of all the accident records was put on a separate file and stored safely. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 Page 22 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 2 2 3 2 2 2 STAFFING Standard No Score 27 1 28 X 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X X 1 2 2 Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 Page 23 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. 1. Standard OP1 Regulation 4(1)(c) Requirement The statement of purpose must include all the information required in Schedule 2 of the Care Homes Regulations including the needs of residents that can be met in the home. (Previous timescale of 01/11/05 partly met.) The service user guide needed to include an overview of complaints and service user views about the home. (Previous timescale of 01/11/05 not met.) An application for variation must be submitted for the service user less than 65 years of age. (Previous timescale of 01/11/05 not met.) The application for variation must also include the individuals who have been diagnosed as having dementia. New residents with dementia must not be admitted to the home. Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 Page 24 Timescale for action 01/05/06 2. OP1 5 01/05/06 3. OP3 4(3)(b) 07/04/06 4. OP2 5(1)(b) 5. OP7 5(1)(b) 6. OP7 13(5) 7. OP7 13(4)(c) All residents must be provided with a copy of the terms and conditions of residence. (Previous timescale of 14/11/05 not met.) The care plans must be updated to include the changes identified in the monthly reviews of residents so that staff have the up to date information about the residents’ needs. 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. (Previous timescale of 14/11/05 not met.) A personal risk assessment must be in place for all residents with strategies for managing the risks. (Previous timescale of 14/11/05 not met.) All risk assessments must be cross-referenced to the care plans. Records of visits made by healthcare professionals must show the reason for and the outcome of the visit. There must be a tissue viability and nutritional screening assessments in place and a plan for managing any identified needs. Residents must be weighed in accordance with the requests made by medical professionals. The balance of medicines carried over from the previous months supply must be recorded on the MAR chart to ensure that it is possible to carry out an audit trail. 01/05/06 01/04/06 14/04/06 14/04/06 8. OP8 12(1)(a) 14/04/06 9. OP8 17(1)(a) Sch3(3) (m) 12(1)(a) 13(2) 14/04/06 10. 11. OP8 OP9 14/04/06 14/04/06 Greenauns DS0000016770.V286043.R01.S.doc Version 5.1 Page 25 12. OP10 12(4)(a) The vacant bedrooms must have the appropriate locks fitted before they are re-occupied. Residents must not be referred to as ‘girls’ but by their chosen form of address. The home must ensure that a suitable programme of activities is in place and the daily records reflect the activities undertaken by the residents. The complaints procedure requires further development to include the information that the complainant can consult CSCI at any stage in the process; the timescales for response and the manager/proprietors could be contacted. 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 and 01/12/05 not met.) 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 and 01/12/05 partly met.) All staff must undertake training in adult protection and whistle blowing. (Previous timescale of 31/05/05 and 01/02/06 not met.) All call points must be maintained in working order and serviced on a regular basis. Evidence that the system has been serviced must be forwarded to the CSCI. A copy of the contract for disposal of clinical waste must be forwarded to the CSCI. DS0000016770.V286043.R01.S.doc 01/05/06 13. OP12 16(2)(n) 01/05/06 14. OP16 22 01/05/06 15. OP18 13(6) 01/05/06 16. OP18 13(6) 01/06/06 17. OP22 23(2)(c) 14/04/06 18. OP26 13(3) 01/04/06 Greenauns Version 5.1 Page 26 19. OP29 19 Sch2 20. OP29 19 Sch2 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 timescales of 09/05/04 and 01/11/05 not met.) The registered person must devise and issue job descriptions in respect of all staff. (Previous timescales of 30/12/04 and 01/11/05 not met.) The registered person must undertake training analysis need assessments for all staff. (Previous timescales of 31/05/05 and 01/12/05 not met.) All staff must undertake mandatory training. An application for registration must be submitted for the new manager. 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 timescales of 30/06/05 and 01/02/06 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. (Previous timescale of 01/01/06 not met.) DS0000016770.V286043.R01.S.doc 01/01/06 01/05/06 21. OP30 18(1)(c) (i) 30/06/06 22. 23. OP31 OP33 18(1)(a) 24 01/06/06 01/02/06 24. OP36 18(2) 01/06/06 Greenauns Version 5.1 Page 27 25. OP37 27 26. OP38 13(4)(c) Regulation 37 notifications must be forwarded to the CSCI as identified in the Care Homes Regulations. The hot water being delivered to the bath on the ground floor must be restricted to 43 degrees centigrade. 01/04/06 01/04/06 27. OP38 23(2)(c) 28. OP38 13(5) All items covered by the COSHH legislation must be kept locked away at all times. Evidence that the gas equipment 01/04/06 and the nurse call system have been serviced must be forwarded to the CSCI. Advice must be urgently sought 01/04/06 on the moving and handling of the resident discussed during the inspection. 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. Refer to Standard OP31 OP32 OP34 OP38 Good Practice Recommendations 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.V286043.R01.S.doc Version 5.1 Page 28 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.V286043.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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