Inspection on 05/09/06 for Handsworth Methodist Home

This inspection was carried out on 5th September 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

Handsworth Methodist Home 24/07/07

Handsworth Methodist Home 06/12/05

Handsworth Methodist Home 01/06/05

Handsworth Methodist Home 21/01/05

Handsworth Methodist Home 17/06/04

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

CARE HOMES FOR OLDER PEOPLE Handsworth Methodist Home West Road Bowdon Altrincham Cheshire WA14 2LA Lead Inspector Val Bell Key Unannounced Inspection 05th September 2006 11:00 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 Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 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. Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Handsworth Methodist Home Address West Road Bowdon Altrincham Cheshire WA14 2LA 0161 928 5314 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) home.fxg@mha.org.uk Methodist Homes for the Aged Mr Mark Greenhalgh Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All service users will fall within the category of old age and may additionally have a physical disability or dementia. The six bedrooms on the 3rd floor are not used for service users who require the use of wheelchairs or those who have poor mobility. Alternative accommodation will be provided should any service users living on the 3rd floor require it in the future. A minimum of four care staff are employed between 8.00am - 2.00pm and 6.00pm - 10.00pm and overall staffing levels will not fall below the minimum requirements set out in the Residential Forum guidelines, `Care Staffing in Care Homes for Older People`. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 6th December 2005 3. 4. Date of last inspection Brief Description of the Service: Handsworth Methodist Home provides residential accommodation with personal care for up to forty-one residents within the category of old age. Handsworth is a private care home owned by Methodist Homes for the Aged. At the time of this inspection the home did not have a registered manager. Handsworth is a large purpose built property set in pleasant grounds that are enclosed and accessible to residents. The home is situated in a quiet residential area of Bowdon within easy reach of a post office, general store, church and local public house. The village of Hale is a short distance away and Altrincham is the nearest main town. The home is conveniently situated for local transport services and main motorway links. The home is arranged over three floors and a passenger lift provides access to all floors. All bedrooms are single and have en-suite facilities. Communal areas consist of a large dining room, several lounges, a conservatory, and activities room and tea bays on each floor. The scale of fees for this home was not available at the time of writing this report. Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted during daytime hours on Tuesday 5th September 2006. During the inspection conversations were held with the staff on duty, fifteen residents and a visitor to the home. A variety of records, including care plans were examined and a tour of the premises was undertaken. Nine satisfaction surveys were completed by residents, or their relatives, and returned to the Commission. The home failed to provide preinspection information as requested. What the service does well: What has improved since the last inspection? The home had developed a risk assessment and management tool although this was not seen in use at this inspection. Residents had been made aware that alternative meals to those on the menu were always available and a resident was seen to be exercising her choice in this area. Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 6 Cleaning schedules for the kitchen and food stores had been implemented and were up to date. The centralisation of personnel records ensured that the required preemployment checks would be undertaken. The safety of residents had been maintained by ensuring that all fire escape routes were free from obstructions. What they could do better: Eleven requirements and three recommendations were made during this inspection. Care planning had deteriorated since the last inspection and this was a cause for serious concern. The residents were confident that their needs were generally being met although there was no written evidence to substantiate this. Care plans had not been reviewed regularly and people with complex physical needs had not been risk assessed. The inspector was told that a care plan training programme was due to commence in October 2006. This needs to be given high priority. Resident files were untidy and disorganised making it difficult to locate specific information. A good practice recommendation was made to develop a filing system for these records. The home was not currently issuing copies of their Service User Guide to prospective residents and a spare copy could not be found for the inspector during this inspection. Significant improvements had been made in the kitchen area. A minor shortfall was noted in that a single item of frozen food was not date labelled. There were also shortfalls in maintaining security of residents’ personal written information that need to be addressed. Fifteen residents and a visitor to the home expressed the view that the home was under staffed. This meant that occasionally the meeting of residents’ assessed needs was being compromised, such as bathing and the option of having a staff escort to go for a walk in the garden. Additionally, staff were lacking the leadership and guidance of a full-time manager. The registered manager had resigned in July and a replacement had not been recruited, although management support was being provided on three days per week. This had not been notified to the Commission in writing, which constituted a breach of Regulation 39 of the Care Homes Regulations. Finally, a good practice recommendation was made to provide residents with a teapot on each table at all mealtimes, in preference to the large catering teapot used at lunchtime on the day of inspection. Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 7 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. Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 8 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 Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 9 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, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are not currently being issued with up to date information that will enable them to decide if the home is the right place for them. EVIDENCE: On the day of inspection the staff on duty could not locate a current copy of the homes Service User Guide. Consequently, the requirement made at the last inspection to review and update the Service User Guide could not be assessed. The inspector was shown the information pack that is provided to prospective residents and the pack did not contain a copy of this document. A resident admitted to the home two weeks before this inspection had not received a copy of the Service User Guide. This appeared to be a recent shortfall as this part of the standard had been met at previous inspections. The home is required to forward a current copy of the Service User Guide to the Commission. Furthermore, this document must be available on request by people making enquiries about admission to the home so that they can make Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 10 an informed choice on whether the home will be suitable to meet an individuals needs. Five residents’ files were assessed and these contained detailed assessments of need. The home did not provide an intermediate care service. Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Residents were confident that their personal and healthcare needs were being met and that they were treated with dignity and respect although there was little written evidence of this. This potentially places the health and welfare of residents at risk. EVIDENCE: Five residents’ care files were assessed during the inspection. These were chosen according to the individuals’ specific care needs as follows: 1. 2. 3. 4. 5. Use of a hoist Frequent falls Sight impairment Pressure sores Newly admitted Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 12 There was no filing system in the residents’ files and information was very disorganised. This made locating specific information difficult and did not provide an audit trail of information from the initial needs assessment to the review of outcomes for residents. A care plan had not been developed for a resident admitted two weeks prior to this inspection and assessment of the remaining four care plans found that there had been a marked deterioration in the standard of care planning in the home. Daily records did not detail the actual care provided to residents, just comments such as, ‘everything fine’ ‘no problems’ and ‘slept well’. Four residents had complex physical needs yet only one care plan contained a moving and handling assessment and this document had not been reviewed since 12th March 2005. The four residents’ needs assessments identified that their physical needs placed them in a high-risk category and yet no risk assessments or risk management plans were in place on any of the care plans. One of the residents had developed a pressure sore, since moving into the home and the district nursing team was monitoring this. There was no evidence in this resident’s daily records that care staff were following the district nurses advice and guidance in managing the resident’s tissue viability and recovery. The correct pressure relieving equipment had been obtained for the resident and staff were able to describe the appropriate personal care needed, but this was not being recorded. In conversation with staff it appeared that this situation had occurred due to a need for care planning training and as a consequence of current staffing shortages including the resignation in July 2006 of the registered manager. The inspector was told that the provider organisation intended to introduce new care planning paperwork along with a training programme for all staff. This was confirmed in a telephone conversation with the area manager following this inspection. One of the residents had fallen out of bed and suffered a skin tear. A second resident had suffered frequent falls in the previous six months and had been referred to the falls clinic. However, these incidents should have prompted care plan reviews and the assessment of risk. It was of concern that this had not taken place in either case. Although the home had developed a risk assessment and risk management tool there was no evidence to show that it was in use. This requirement has been outstanding since 1st September 2005 and must be given urgent priority. However, it is reassuring to note that the fifteen residents interviewed praised the staff for the way that their personal care is delivered and their needs met. The spokesperson for a group of four residents that the inspector sat with during lunch said, “We haven’t got a bad word to say about any of them” (the staff). However, all fifteen residents told the inspector that more staff are needed as “the carers are run off their feet.” The inspector observed the lunchtime administration of medication to residents. It was noted that medication was signed for at the time of dispensing from the blister pack and the member of staff did not observe Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 13 people taking their medicine. The medication administration records were well maintained and up to date. The member of staff administering medication had completed the Boots basic medication training and was awaiting a date to attend the advanced training. The outstanding requirement relating to the security of confidential information has been re-iterated in this report. On this occasion personal information had been included on handover forms and records detailing the bowel movements of certain residents. All personal information relating to residents must be securely held in their individual records in line with data protection and freedom of information legislation. All residents spoken to confirmed that staff treated them with respect and that their right to dignity is upheld. Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Residents are able to enjoy a full and stimulating life style with a variety of options to choose from. Robust systems in place offer residents financial security. EVIDENCE: The home employs an activity co-ordinator and all residents spoken to were very enthusiastic about the variety and regularity of the activities on offer. One resident said, “I have lived in a home where there was very little of interest going on. I moved in here and by the following afternoon I had joined the art class. There’s always something going on. Tomorrow, seventeen of us are going on a trip to Arley Hall. We also have regular exercise classes. I had not been walking for several months but now I’m back on my feet thanks to their encouragement.” During lunch, three residents said they enjoyed playing Scrabble every afternoon and one lady said she enjoyed regular attendance at the local Methodist church. Several residents confirmed that the home had developed close links with local churches of all denominations. It was clear that the progress identified at the last inspection had been maintained for which the home received a commendation. Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 15 Four residents stated that their relatives were always made welcome when they visited and a conversation was held with a resident’s son during this inspection. This relative said, “I wouldn’t single any of the staff out as they are all dedicated and caring. They go out of their way to make sure that my father has everything he needs. I do think that there should be more staff though. The carers never stop and I know that a lot of them work very long hours and some even come in on their days off.” The inspector joined four of the residents during the midday meal. There was a choice of two main meals on the menu and these were nutritious and attractively presented. One resident had ordered an alternative meal as she had limited tastes in food. She said that there are always alternatives available if you ask. The kitchen and storerooms were found to be clean and hygienic and temperature records and cleaning schedules were up to date. The cook was very knowledgeable in relation to residents’ special diets. Two minor shortfalls were noted. Rissoles had been removed from their original packaging and had been stored in the freezer without descriptive labels and dates. After the lunchtime meal staff served tea from a large catering teapot, which looked institutional and was not in keeping with the homely atmosphere that is expected. When questioned about this, staff said that at teatime each table is provided with their own teapot enabling residents to serve tea themselves. A recommendation was made for this to be adopted at all mealtimes. Since the last inspection there had been a series of thefts of residents and staff personal monies. This had been referred to the local authority adult protection procedures and involved police guidance. This had been handled well by the home and action had been taken to implement more robust financial procedures that ensured residents financial interests were protected. Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Robust policies and procedures offer protection to the welfare and safety of residents. However, the way that the home’s records complaints potentially places the confidentiality of residents’ personal information at risk. EVIDENCE: Since the last inspection the home had reverted to the previous practice of recording complaints in a hard-back book, which did not comply with data protection and freedom of information legislation. Complaints must be recorded separately using the organisations available recording system. However, it was evident that complaints were being managed well. Residents confirmed that staff listen to them, take their views seriously and take appropriate action when they have concerns. Robust policies and procedures for the protection of vulnerable adults from abuse were in place. Since the last inspection the home had managed adult protection issues well by working closely with the local authority and police and had taken the necessary action to minimise the risk of further occurrences. Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are provided with a pleasant, comfortable and safe living environment. EVIDENCE: A tour of the home was undertaken. The environment was well maintained and fixtures and fittings were domestic in nature. The home was found to be clean and hygienic and no unpleasant odours were present. Environmental adaptations and disability equipment had been provided to meet the assessed needs of residents. Residents had personalised their bedrooms to reflect their individual preferences and personal interests. Tea bays were provided on each floor and this had extended resident choice in where they could have breakfast or engage in activities. Since the last inspection the garden had been attractively landscaped to provide a variety of sensory areas. This demonstrated that the home valued the diverse needs of the residents by Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 18 providing the facilities for all residents to enjoy meaningful lifestyles. Several residents remarked about how lovely the gardens were and one lady said she enjoyed walking round the garden on a daily basis. Residents had access to all communal areas in the home and were observed freely moving about during the inspection. Appropriate laundry and washing facilities were provided and robust procedures for the control of infection were in place. Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Residents were confident that their personal care needs were generally being met. However, due to the current staffing levels it was evident that some shortfalls existed. This potentially places the health, welfare and safety of residents at risk. EVIDENCE: On the morning of this inspection four care staff were on duty including a senior carer who was the person-in-charge. All residents and a visitor spoken to commented about staffing shortages since the resignation of the registered manager in July. In conversation with staff it was noted that some staff were working regular double shifts to provide basic cover for staff absences. Throughout the inspection the staff on duty were constantly interrupted in having to answer the door bell, telephone and nurse call system and it was difficult for them to balance this with meeting the residents needs. This was compounded by the absence of management or administration presence throughout the day. Some residents stated that this situation had on occasion meant that they had missed their weekly bath. One resident asked if a member of staff could escort her on her daily walk round the garden and the member of staff replied, “If we have time.” The registered person must ensure that staffing levels are reviewed to ensure that sufficient staff are deployed to meet the assessed needs of the residents. Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 20 Care staff had been enrolled on NVQ courses in care. However, the inspector was told that progress was slow owing to the current staffing situation. Since the last inspection the organisation had centralised the personnel records at their head office in Derby. Inspectors had been given assurance that the required pre-employment checks would be obtained prior to confirming new staff in post and that the Commission would monitor the records annually. Training records were not examined on the day of the inspection as staff stated that training was currently on hold as there were not enough staff to provide cover. This is an issue of concern as it was identified that there was an urgent need for staff development in the area of care planning and record keeping. The area manager said that a training programme was planned to commence in October 2006. Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 21 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, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is without a registered manager and the staff are lacking consistent leadership and guidance. This potentially places the health, wellbeing and safety of residents at risk. EVIDENCE: On arrival at the home the inspector was told that the registered manager had resigned in July 2006. This had not been notified in writing to the Commission as required under Regulation 39 of the Care Homes Regulations 2001. A letter of serious concern was sent to the responsible individual informing that the organisation was in breach of regulations. Following the inspection the area manager informed the inspector that a letter had been drafted but it appears that this went astray. The current management arrangements involved Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 22 another home manager and the area manager providing cover for three days per week. However, it was clear that on the days when cover was not being provided staff employed in the home were working at full capacity with no margin for flexibility. This was confirmed by the comments of fifteen residents and all residents spoken to expressed their concern that a new manager had not been recruited. This situation is not in the best interests of residents and must be addressed. The home had recently issued satisfaction surveys to residents and their representatives. This was done on an annual basis. Residents confirmed that the home values their views on the quality of care they receive. Robust procedures for the security of residents’ finances were in place and staff were observed to undertake a daily check of the monies held on behalf of residents. There were no health and safety issues identified during this inspection. Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 23 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 1 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 5 (2) Requirement The registered person must supply a copy of the Service User Guide to the Commission and each resident. The registered person must ensure that a care plan is prepared for each resident and this plan must be kept under regular review. The registered person must implement a risk assessment (including moving and handling assessments) and risk management tool. Previous requirement timescale of 01/09/05 not met. The registered person must ensure that accurate records are held in relation to meeting residents health needs e.g. pressure sores. In particular the care provided as advised by health professionals must be recorded in detail. The registered person must ensure that a safe system of the administration of medication is in place. Timescale for action 05/10/06 2. OP7 15 05/10/06 3. OP7 13 (4) 05/10/06 4. OP8 2 (1) 05/10/06 5. OP9 13 (2) 05/10/06 Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 25 6. OP10 17 (1) (b) 7. OP15 13 (4) The registered person must ensure that residents personal information is held securely in their individual care plans. Previous timescale of 06/02/06 not met. All food stored in the home must be date labelled to allow for stock rotation with the use by dates. Previous timescale of 06/02/06 not met. Complaints must be recorded individually to ensure that the confidentiality of residents’ personal information is protected. The registered person must ensure that sufficient staff are deployed to meet the assessed needs of residents. The registered person must ensure that staff receive suitable, assistance, including time off, for the purpose of obtaining further qualifications. The registered person must inform the Commission in writing of the resignation of the registered manager and detail the interim arrangements for management cover at the home. 05/10/06 05/10/06 8. OP16 12 (4) (a) 05/10/06 9. OP27 18 (1) (a) 05/10/06 10. OP30 18 (1) (c) 05/10/06 11. OP31 39 12/09/06 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. Refer to Standard OP1 Good Practice Recommendations The home should have an available supply of Service User Guides for people enquiring about admission to the home. DS0000005609.V305982.R01.S.doc Version 5.2 Page 26 Handsworth Methodist Home 2. 3. OP7 OP15 The home should consider implementing a filing system for the care plans to provide an audit trail from assessment, care planning and monitoring to review. The home should consider providing residents with teapots on their dining tables at all mealtimes. Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Handsworth Methodist Home DS0000005609.V305982.R01.S.doc Version 5.2 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. 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