Inspection on 28/11/05 for Herondale

This inspection was carried out on 28th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Herondale 19/11/08

Herondale 21/02/08

Herondale 10/10/06

Herondale 07/07/05

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Herondale 175 Yardley Green Road Yardley Birmingham West Midlands B9 5PU Lead Inspector Ann Farrell Unannounced Inspection 28th November 2005 08.40 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 Herondale DS0000063695.V270297.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. Herondale DS0000063695.V270297.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Herondale Address 175 Yardley Green Road Yardley Birmingham West Midlands B9 5PU 0121 7531653 0121 7714188 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) Methodist Homes for the Aged Care Home 36 Category(ies) of Dementia - over 65 years of age (36), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (36) Herondale DS0000063695.V270297.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home can accommodate up to 36 older people over the age of 65 years with dementia or who have a mental illness and may also be infirm. (DE(E)) and (MD(E)) That the home can accommodate one named service user under 65 years of age with dementia. 7/7/05 2. Date of last inspection Brief Description of the Service: Herondale is a purpose built; two storey home that is registered to provide care to 36 residents for reason of mental health problems, predominantly dementia. It is situated in a residential area within the boundary of Heartlands Hospital; it is close to shops, local amenities and is accessible to public transport systems. There is adequate parking to the front of the building with and large enclosed garden to the rear, which has a patio and seating for use by residents when weather permits. The home is divided into four wings or house groups spread over the ground and first floors. The first floor is accessible by the stairs or a passenger lift. Each house group has its own lounge, dining area, kitchenette, a bathroom, a communal toilet and nine en-suite bedrooms. The en-suite facilities consist of a toilet and shower facility. The main kitchen and laundry area are situated on the ground floor, which are staffed separately. The home has recently been taken over by Methodist Homes. The staff group remain fairly stable. Herondale DS0000063695.V270297.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 one day on 28th November 2005 commencing at 8.40am. This was the second statutory inspection for 2005/2006. This report should be read in conjunction with the report of the inspection conducted in July 2005 to obtain an overall view of the home. A senior nurse was present for the duration of the inspection. During the inspection process the inspector toured the home, undertook case tracking of some residents files in addition to inspection of other documentation. The senior nurse, two members of staff, two residents and one relative who was visiting were spoken to. At the time of inspection a number of residents in the home were unable to verbally communicate. What the service does well: The home provides specialist care for residents with advanced dementia. They have a philosophy of celebrating what residents can do and provide person centred care. There is a relaxed atmosphere with flexible routines in the home. The relatives spoken to stated they were happy with the care provided by the home and found the staff very good. It was stated, “ they are well looked after”. The building is purpose built and provides adequate space for residents to wander around as they wish. The home has been working with the Bradford Dementia group and is constantly looking at ways of improving the life of residents and currently researching ways of making daily activities more pleasurable for residents. Staff regularly observe residents to assess their level of wellbeing through dementia care mapping and results have been consistently high. Visiting is flexible and relatives are encouraged to become involved in the care given to the residents. The home holds meetings with relatives/carers regularly. The home has a staff development programme in place with regular staff meetings and formal staff supervision to ensure they have the support they need to meet residents needs. All bedrooms are single en-suite rooms with shower and toilet facilities. The home is divided into small groups for nine residents providing a more homely atmosphere. Herondale DS0000063695.V270297.R01.S.doc Version 5.0 Page 6 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. Herondale DS0000063695.V270297.R01.S.doc Version 5.0 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 Herondale DS0000063695.V270297.R01.S.doc Version 5.0 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): 3,4,6 The home has information available for prospective residents or their relatives enabling them to make an informed decision about moving into the home. Procedures for admission are satisfactory, but records need developing to ensure all residents’ needs are identified and met. EVIDENCE: Herondale provides specialist mental heath nursing care for older adults on a long-term basis and aims to meet their needs in a creative way following normal life patterns. They have been involved with research projects with the Bradford Dementia Group and are continually looking at ways to improve the quality of life for residents. The home is managed and run by suitably qualified nurses, who appeared enthusiastic and committed. The home does have written information for prospective residents and their families, but this was not inspected. At the time of previous inspections the statement of purpose required enhancing. Following admission to the home comprehensive assessments are undertaken and a care plan drawn up for all residents. Herondale DS0000063695.V270297.R01.S.doc Version 5.0 Page 9 A small sample of resident’s files were inspected and found the assessments to be of varying detail. Some provided good detail, but others were lacking in detail, some risk assessments had not been fully completed, in one case file there was no evidence of a risk assessment for bed safety rails and the manual handling assessments did not indicate the action to be taken if a resident had fallen. At the last inspection the manager stated that they were looking at developing the assessment process prior to admission to enable further information to be obtained from relatives and encouraging them to take a more active part in the care if they wished. There was no evidence available to demonstrate that this had been implemented yet. Herondale DS0000063695.V270297.R01.S.doc Version 5.0 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): 7,8,9,10 Shortfalls in the recording system cannot guarantee that resident’s needs are consistently met. The systems for medicine management within the home are good. These need to be adhered to at all times to ensure resident’s medication needs are met. EVIDENCE: The home draws up care plans for individual residents outlining the action required by staff to meet resident’s needs. On inspection of a small sample of them they were found to be of varying detail. Some were found to provide good detail, but others were vague, some areas had not been completed or dated and in one case the instructions from a physiotherapist had not been included in the plan of care. Nutritional assessments had been undertaken, but there was no evidence of an objective tool such as body mass index and some residents had not been weighed, as the home did not have suitable equipment available to weigh them. Nurses complete daily records and in addition carers complete the handover book with details about the care given. It was noted that the handover book had details about all residents and areas of concern had been identified, but Herondale DS0000063695.V270297.R01.S.doc Version 5.0 Page 11 there was no evidence of follow up in the nurse’s records or the handover book. Also it was noted that the records on one house group were on show in a cabinet and available to anyone who entered. The manager will need to review the system of storage and recording in the handover book to ensure confidentiality is maintained. On discussion with some relatives who were visiting the home they praised the home and the staff stating they were happy with the standard of care and cleanliness. One stated, “ They are looked after well”. It was noted that some relatives were involved with aspects of care if they wished. The pharmacist inspector undertook an inspection of the medication and found the home had a robust medication policy and the majority of staff adhere to it. The management do not undertake staff drug audits to identify the nurses responsible for some poor practice identified during the inspection. Some medicines had been signed as administered when they had not been, some were unaccounted for and some had not been signed as administered when they had been and others had not been given with no reason for non administration recorded in a few instances. All medicines administered from the Monitored Dosage System (MDS) were accurate at the time of the inspection. The home has a robust checking in procedure for all medicines received on a monthly basis but this is not used for any extra medicines received mid month. Quantities of medicines received had been recorded enabling medicines to be audited, but carry over balances from previous cycles had not been routinely recorded. The home demonstrated some good practices for the administration of medicines with unusual dose regimens well documented, but written protocols for occasional use drugs were not evidenced. The home failed to correctly store medicines awaiting removal by a clinical waste company. However,this was to be rectified after the inspection following the delivery of clinical waste bins. The medication room was too hot at the time of the inspection. The refrigerator temperatures were too hot and did not fall between 2° and 8°C to comply with the medicines product licences. Herondale DS0000063695.V270297.R01.S.doc Version 5.0 Page 12 All rooms have en-suite facilities, doors have locks and a lockable facility and keys are available to residents or their relatives. Staff were noted to respect residents privacy and treat them with respect. Residents are able to get up and go to bed as they wish as the home operates a system of natural waking. Staff were noted to interact with residents appropriately and were aware of their needs. A portable telephone is situated on the ground floor and rooms have telephone sockets enabling telephone calls to be made in private. Herondale DS0000063695.V270297.R01.S.doc Version 5.0 Page 13 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 There is a relaxed, friendly atmosphere and residents are free to do as they wish. Visiting is flexible and there are good relationships between staff and relatives. Staff support residents to maintain contact with family and friends, who are able to be involved with residents care if they wish. There is a range of opportunities for occupation, but it could not be evidenced due to the lack of records in this area. EVIDENCE: Herondale DS0000063695.V270297.R01.S.doc Version 5.0 Page 14 The home has flexible routines allowing natural wakening and residents are supported by staff in making choices about various aspects of life. Snoozlam equipment is available and is now used in resident’s rooms. The home has an open visiting policy and on discussion with relatives they stated staff were very good and they could visit at any time. It was noted that some relatives were involved with care and were providing assistance with feeding. The staff hold a relatives forum approximately every six months. There is a range of activities, which include a religious group who visit each week, pub sessions, visits by entertainers, pet therapy and there have been outings to the Botanical gardens, Twycross Zoo and Cannon Hill Park. Staff stated they are trying to make daily activities more pleasurable for residents and are currently researching engagement of residents on their own volition. This involves leaving a range of objects around the home enabling residents to handle them and become involved or alternatively staff may have some involvement by taking the objects to the resident. Although it was noted that there were a range of objects around the home records inspected did not verify engagement or activities and this aspect of care was not evidenced at the inspection. The garden provides a potting shed, raised flowerbeds and garden furniture for use when the weather permits. Herondale DS0000063695.V270297.R01.S.doc Version 5.0 Page 15 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): 18 Staffs knowledge of adult protection procedures need to be improved to ensure residents are safeguarded at all times. EVIDENCE: The home has a policy/procedure in respect of abuse and it refers to the local multi-agency guidance. On discussion with the nurse in charge he was unable to produce a copy of the local guidance and there was some lack of clarity about the procedures. On inspection of records it was noted that there had been an incident involving two residents and there was no evidence that the social workers or the Commission had been informed. Also it was noted that one resident was restrained with a belt when sitting in a chair. There was no record of this in the care plan and there was no evidence of a multidisciplinary meeting to discuss the options. The manager will need to call a multidisciplinary meeting to discuss the resident’s needs and in future all incidents must be reported to the Commission and social worker where appropriate. Herondale DS0000063695.V270297.R01.S.doc Version 5.0 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): There is a relaxed calm atmosphere. Further decoration and refurbishment is required to enhance the homeliness of the environment. EVIDENCE: Herondale DS0000063695.V270297.R01.S.doc Version 5.0 Page 17 The home is purpose built and is divided into four units/house groups. Each house group has nine en-suite rooms with a lounge, dining area and small kitchenette. The home was clean, odour free and generally well maintained. Some re-decoration has been undertaken recently and new carpets have been fitted in the reception area and corridors. However, further decoration and refurbishment is required to enhance environment. The lounges look rather sparse and dining tables need replacing. There is a large enclosed garden to the rear of the building with a patio; garden furniture and a potting shed to be used when weather permits. The garden can be accessed by the ground floor lounges and provides an enclosed wandering space with a telephone box, sewing machine and beach area for residents to explore. Baffle locks were fitted to all doors and rooms that may be hazardous to residents had coded keypads to ensure residents safety. However, the locking mechanism on the gate at the bottom of the stairs was broken. All bedroom doors have a lock and rooms have lockable facilities. En-suite facilities consist of a toilet wash hand basin and shower. A new call bell system has been fitted with pressure mats where required. Furnishings were domestic in nature some are in need of upgrading in communal areas. A small sample of rooms were inspected and they were found to be of a good standard and had been personalised by residents and their families. Each of the four house groups has an assisted bath facility, accessible from both sides and there are communal toilets. Recently a new parker bath has been fitted and some of the tiling needs to be addressed in order to complete the bathroom. All areas are individually and naturally ventilated and windows are provided with restrainers. All areas are centrally heated with low surface temperature radiators to reduce the risk of scalding. Laundry facilities were sited on the ground floor. It was noted that a pair of rubber gloves were in use for soiled items. It was not clear if they were re used. The manager will need to review the procedures. A new chef has been recruited since the last inspection and he stated he has reviewed the menus. It was noted that there is no dishwasher and potatoes were stored on the floor. The Chartered Institute of Environmental Health – food safety first principles state that there should be two sinks and the items should be washed in the first sink at 55 degrees centigrade. Items should then be rinsed in hot water 82 degrees centigrade in the second sink leaving them to soak for 30 seconds using a designated basket for the purpose if possible. Items should be left to air dry in a clean dry area. This practice was not observed at the time of inspection and the manager will need to review this area. Herondale DS0000063695.V270297.R01.S.doc Version 5.0 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): 27,28,29 Staff morale was good and there was noted to be good relationships between staff and residents. The staffing levels are satisfactory to meets residents needs. Training is ongoing with over 50 of care staff having completed NVQ level 2. EVIDENCE: Duty rotas indicated that there are two nurses and seven carers on duty during the day with one nurse and four carers overnight. Staff members are divided into teams who usually work together. The home employs ancillary staff to support the care staff and at the time of inspection the staffing levels appeared satisfactory for the current dependency of service users. A small sample of staff files were inspected and demonstrated a robust recruitment procedure. However, it appears the Nurses PIN numbers are not checked directly with the NMC. Arrangements will need to be implemented to address this and it is recommended that they be checked on a regular basis. There is ongoing training in the home with over 50 of care staff having completed NVQ level 2 and induction training is undertaken for new employees. Herondale DS0000063695.V270297.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): 31,33,35,38 The manager, who is supported by the senior team, has suitable systems in place for the management of the home. The home is managed in the interests of the residents and their health, safety and welfare is protected. EVIDENCE: The manager is a registered nurse and has a number of years experience. Currently she is not registered with the Commission and an application for registration will need to be forwarded to the Commission to enable to process to commence. Staff were relaxed and friendly. They stated they enjoyed working in the home and found all the nurses approachable. They confirmed that staff meetings occurred regularly and formal supervision was undertaken every six weeks. The nurse in charge stated that a quality monitoring system is to be introduced in the near future. Herondale DS0000063695.V270297.R01.S.doc Version 5.0 Page 20 Currently they undertake dementia care mapping to determine the well being of residents. There was evidence of regular visits from a manager and reports are written as required under Regulation 26. The home holds some monies in a residents account on behalf of residents and records/receipts were available. However, there was only one signature for some transactions and money had been given to a key worker to purchase some items for a resident. There was a note in the wallet to explain the discrepancy in the records and the balance, but it appears that there is no formal procedure for dealing with this and checking items bought. It is recommended that this be reviewed and a local procedure drawn up if necessary. Also it appears that the company hold money on behalf of residents in an account at head office, and the home request money when required and it is deposited into a bank account that they can access. However, they have no knowledge of the account and the amounts of money held on behalf of residents in the home. The Regulations require that the bank account should be in the resident’s name/names and records must indicate the details of money deposited on behalf of the residents. This area will need to be reviewed. On discussion with some staff there was a lack of clarity in respect of the fire procedure. All accidents had not been consistently recorded in the accident book. The Commission had not been informed as required under Regulation 37 of all these incidents and the nurse was not sure if any auditing of accidents was undertaken. If the home does not currently have a system for auditing accidents it is recommended that this be commenced. Also there is no record of food taken by residents maintained in the home to enable the home to demonstrate that residents receive a healthy diet.. Herondale DS0000063695.V270297.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 X X 2 3 X N/A 2 2 3 3 3 3 3 2 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 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 3 2 2 Herondale DS0000063695.V270297.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. 1. Standard OP3 Regulation 14 Requirement The registered person must ensure all assessments of residents needs are comprehensive upon admission to the home and include full risk assessments. Timescale of 30/8/05 not met. The registered person must ensure a comprehensive care plan is drawn up for all residents in the home outlining in detail the action to be taken by staff to meet their needs. The care plan must be updated when any changes are noted. Timescale of 30/8/05 not met. The registered person must ensure that daily recording indicate follow up to all areas of concern identified. Timescale of 10/7/05 not met. The registered person must review the arrangements for recording in the handover book and the storage of files in house groups to ensure they meet the data protection act and maintain confidentiality at all times. The registered person must DS0000063695.V270297.R01.S.doc Timescale for action 30/01/06 2. OP7 15 30/01/06 3. OP7 17(2) 20/12/05 4 OP7 17(1) DPA 30/12/05 5. Herondale OP8 12(1) 30/01/06 Page 23 Version 5.0 6 OP8 13(4) 7. OP8 14 8 OP9 13(2) ensure appropriate equipment is available in the home for weighing all residents. The registered person must 20/12/05 ensure bed safety rails are used on both sides of the bed including beds situated next to the wall. The registered person must 30/12/05 ensure a nutritional assessment is undertaken for all residents on admission to the home and reviewed periodically. An objective tool such as BMI should be incorporated in to this process. The registered person must 05/12/05 ensure: All medication including those awaiting removal from the clinical waste company must be securely locked in cabinet and Controlled Drugs (CD) stored in a CD cabinet. The registered person must ensure; • Staff drug audits are undertaken to confirm staff competence in medicine management and appropriate action must be taken when discrepancies are found. All “when required” medication must have a supporting protocol written reflecting its correct indication. Outcomes following administration must be recorded. 12/12/05 • 9 OP9 13(2) 17(1) 28/12/05 • 10. OP9 13(2) The registered person must ensure: DS0000063695.V270297.R01.S.doc Herondale Version 5.0 Page 24 • • The temperature of the medication room must fall below 25°C at all times to ensure the stability of the medicines stored within. The medicine refrigerator temperatures must lie between 2°C and 8°C at all times to ensure the stability of medicines requiring refrigeration 11 OP12 12(1) 12 OP18 13(6) 13 OP19 16(2)(j) The registered person must 30/12/05 ensure a record of activities, stimulation and engagement with residents is maintained to demonstrate this aspect of care. The registered person must 30/12/05 ensure: • A copy of the local guidance in respect of vulnerable adult procedures is available and all staff are aware of it. • Where there are any incidents between residents the social worker is informed. • A multidisciplinary meeting is convened in respect of the resident where a belt is being used in the chair. Records must be maintained of the meeting and recommendations implemented. 30/03/06 The registerd person must: Undertake a review of the procedures for washing up in the main kitchen and appropriate action taken to meet the standards. • Ensure food items are not stored on the floor. The registered person must undertake an audit of the home DS0000063695.V270297.R01.S.doc • 14 OP20 16(2)© 23(2)(d) 30/12/05 Herondale Version 5.0 Page 25 15 OP20 13(4) 16 OP26 13(3) 17 OP29 19 18 OP31 8(1) 19 OP33 24(1) 20 OP35 20 and draw up a plan of decoration and re-furbishment. Forward the plan to the Commission with timescales for work to be completed. The registered person must ensure the gate at the bottom of the stairs is fixed or an alternative put in place. The registered person must review the arrangements in respect of infection control in the laundry area. The registered person must ensure nurses PIN numbers are checked on commencing employment in the home and it is recommended that they be checked on a regular basis. The responsible person must ensure an application is forwarded to the Commission for the registration of the manager. The registered person must introduce a quality assurance system seeking feedback from stakeholders and draw up a plan indicating outcomes for residents. The Registered Person must ensure: That where money is deposited in a bank on behalf of a resident the account is in the residents name and they must retain details of all monies held on behalf of the residents. • Two people must sign all transactions. The registered person must ensure a record of food taken by residents in sufficient detail for those inspecting the record to determine whether the diet is satisfactory. The registered person must all DS0000063695.V270297.R01.S.doc 20/12/05 20/12/05 20/12/05 30/01/06 30/03/06 30/03/06 • 21 OP37 17(2) Sch 4 20/12/05 22 Herondale OP38 23(4)(e) 30/12/05 Page 26 Version 5.0 23 OP38 37 staff are fully conversant with the fire procedure. The registered person must ensure all accidents are recorded in the accident book and the Commission is informed of all incidents affecting the well being of residents 20/12/05 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 Refer to Standard OP3 OP35 OP38 Good Practice Recommendations It is recommended that the manual handling assessment is reviewed It is recommended that the home draw up a procedure outlining the arrangements for monies given to staff purchasing items for residents and checks undertaken. If the home does not currently have a system for auditing accidents it is recommended that this be commenced. Herondale DS0000063695.V270297.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 Herondale DS0000063695.V270297.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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