Inspection on 05/05/05 for Madeleine House

This inspection was carried out on 5th May 2005.

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

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

Other inspections for this house

Madeleine House 22/02/10

Madeleine House 09/11/09

Madeleine House 19/10/09

Madeleine House 26/08/09

Madeleine House 24/06/09

Madeleine House 11/07/07

Madeleine House 24/08/06

Madeleine House 23/11/05

Madeleine House 10/12/04

Madeleine House 09/06/04

Madeleine House 20/11/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Madeline House 60 Manor Road Stechford Birmingham B33 6EJ Lead Inspector Ann Farrell Unannounced 5th May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Madeleine House Address 60 Manor Road Stechford Birmingham B33 0EJ 0121 786 1479 0121 786 0621 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Anchor Trust Matthew Bell Care Home 41 Category(ies) of Learning disability over 65 years of age (41), registration, with number Old age, not falling within any other category of places (41), Physical disability over 65 years of age (41) Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. 41 Service Users for reason of Learning Disability over 65 years of age (41), Old age no falling within any other category (41), Physically Disability over 65 years of age (41). 2. Minimum staff levels to be maintained at - 4 care staff thoughtout the day, and two care staff overnight in additional to the manager, deputy manager and ancilliary staff. Plus an activties co-ordinator for at least 20 hours per week. 3.That Mr Bell successfully completed the Registration Manager Award (NVQ Level 4 Management of Care) or equivalent by April 2005. 4. That Mr Bell successfully completes recognised training module in caring in people with dementia by April 2005. 5. That Mr Bell successfully completes training in respect of continence and infection control by March 2004. Date of last inspection 10th December 2004 Brief Description of the Service: Madeline House provides accommodation for 41 residetns who are over 65 years of age and require assistance for reason of old age and physical disability. The home is owned and managed by Anchor Trust. It is a modern two storey building set back off the road in its own grounds with adequate parking to the front of the building. The home is well maintained internally and externally with a garden to the rear of the property and access can be gained from the dining room patio doors and a ramp. Accommodation is provided in 41 single bed-sitting rooms. All rooms have ensuite facilities that consist of a toilet and wash hand basin and in addition there is a small kitchen area in each flat with a fridge. Communal space comprises of a lounge/dining room on the ground floor and a small quiet sitting room on the first floor. . The home has a passenger lift with gives access to all areas and range of equipment for moving and handling residents. There are a number of bathrooms and shower rooms strategically placed around the home, some of them having recently been refurbished. The home is well placed with easy access to public transport, shops, pub and swimming baths. Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted on an unannounced basis over a full day commencing at 7.45am on 5th May 2005. The registered manager and deputy were present for the duration of the inspection. During the inspection process the inspector toured the home, sampled residents files and other documentation. The managers, two members of staff, approximately ten residents and one relative who was visiting were spoken to. Resident’s views were very positive stating that they enjoyed the company in the home. They stated the staff were very very good, the food was good and they received a choice with ample portions. They were satisfied with the standard of the laundry and had no complaints. One resident stated, “ I have been here fourteen years and have no complaints”. What the service does well: The home is friendly, relaxed and homely. The manager’s office is situated in the main reception area enabling visitor’s easy access to discuss any issues or concerns. The relative visiting stated that they always found the home clean on visiting, they can visit at any time, staff were always pleasant and friendly, they were kept informed of any problems. They stated “ they are always there to help you” The staff stated they were happy working in the home and enjoyed going to work. They felt they worked well as a team and found the managers professional, approachable and supportive. The deputy manager works with care staff on the floor and they are prompt in noting changes in resident’s conditions. Staff are friendly and welcoming and there was noted to be a good rapport and relationships between staff and residents. Routines are fairly flexible and there is no restriction on visiting. The deputy manager works with care staff and staff are prompt in noting changes in residents conditions. The home provides a varied menu with a choice of meals and ample portions, which was appreciated by residents. The home is clean and well maintained providing a safe environment. Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 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. Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4,5, There was noted to be good procedures and staff knowledge in respect of residents being admitted to the home. Further development of assessments and care plans is required to ensure good communication of needs to all members of staff. EVIDENCE: The home has information available for prospective residents and their representatives in the form of a welcome pack. On admission to the home all residents receive one and a card welcoming them to the home. At the time of visiting the inspector spoke to a resident who had recently moved into the home who was satisfied with everything. She stated her daughter had taken the information home and it was noted that the welcome card was displayed in her flat. In addition, the home has a statement of purpose and service users guide available in the reception area. The home liaises with social workers who provide written assessments/care plans for residents who wish to enter the home. They also invite prospective residents to the home enabling them to view the facilities, meet staff and other residents and partake in a meal. At this stage the home is able to undertake an initial assessment to determine if they are able to meet residents needs. Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 9 Following admission to the home a more comprehensive assessment is undertaken and an individual lifestyle agreement (ILA) is drawn up and there is a trial period of one month when a review is held with the resident, staff and family. On inspection of the records relating to admission there was noted to be an improvement in the records relating to the assessment with some providing a good range of information. On discussion with the deputy manager she was very knowledgeable about residents condition and needs demonstrating a caring attitude. It was pleasing to see the developments to date, but some further work will be required to provide a consistent approach in recording to ensure clear communication of information to all staff. The home has applied for a variation to their registration to enable them to admit residents with dementia, which is currently under consideration. In order to be able to meet the needs of these residents the managers and staff have undertaken some specific training. The manager also stated that the deputy manager and himself are hoping to undertake some more in depth training. Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 There are good systems in place to meet health care needs and there have been improvements in the medication system. Although staff have a good understanding of residents needs and there are positive relationships the shortfalls in the recording system cannot guarantee consistency. EVIDENCE: The home draws up an individual lifestyle agreement (ILA) for each resident following admission to the home outlining how the resident’s needs are to be met by staff. On inspection of a sample of records they were found to be vague in areas, lacking detail and all needs had not been included in the plan of care. In one case it was noted that there was no plan of care for a resident who had been in the home for over a month. It was also noted that they had not be reviewed on a monthly basis and changes in treatment /care had not been included in the plan. In one instance a resident had commenced treatment in respect of an aspect of behaviour and the home had not commenced any method of evaluating response to the treatment except through verbal communication. Daily records were basic and did not consistently indicate follow up/monitoring of areas of concern. On talking to senior members of staff they demonstrated a good knowledge and were aware of needs and issues, but this is reliant on them always being Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 11 available plus good communication and memory. In order for a consistent approach to care detailed care plans should be in place for all staff to access. Manual handling assessments had been completed, but there was little evidence of any other risk assessments and where some risks had been identified there was no indication of the action to reduce the risk. The home has good systems in place for monitoring health and nutrition and liaise with health professionals as required There had been a marked improvement in the medication system since the last inspection, which was pleasing to note. There are still some areas that require attention, as some of the audits undertaken were not accurate, the administration of creams had not been consistently recorded, codes had not been explained, variable dose prescriptions were not clear and an oxygen cylinder had not been secured. All staff have completed the medication training and managers have been advised to undertake more frequent auditing of the medication in order to address these issues. On discussion with resident’s they stated they were happy living in the home, found the staff very good and they responded promptly to call bells. They confirmed they had keys to their doors and the home was in the process of fitting lockable facilities in flats. Some have had a telephone installed in their own room and a pay phone is available on the ground floor, which has been partially partitioned. In addition, there is a telephone available in the small lounge area on the first floor It was noted that staff respected resident’s privacy and there was evidence of consultation with residents. At the time of inspection all residents were well presented. Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Catering and meals are well managed with a choice and variety available. Residents are able to make choices about daily living activities and there is a relaxed atmosphere in the home with a range of leisure activities available. EVIDENCE: The home employs an activities co-ordinator who works twenty hours per week and a programme of activities is organised. On discussion with residents they stated they appreciated the activities, but did get bored at times and would appreciate more. On inspection of files it was noted that the activities coordinator had spoken to some residents about activities, but it did not clearly indicate that areas of past interests and hobbies had been explored in order to expand the current range of activities available in the home. It is recommended that this be reviewed. Currently progressive mobility visit monthly, the home has a karaoke machine, television and music centre in the lounge. They have bingo sessions, visiting entertainers, shopping trips and one to one sessions. They celebrate events such as Easter, Christmas, New Year and birthdays. The home sells greeting cards and some of the staff are undertaking a sponsored slim to raise money for the residents fund. One of the residents goes out to a day centre three times a week and others go out with family on a regular basis. Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 13 The hairdresser visits the home on a regular basis. Ministers of various denominations visit and a service is held in the home each month. Visiting is fairly flexible and service users have a choice of areas to receive visitors, which was evidenced at the time of inspection from discussion with a relative. On discussion with residents and staff it was stated that they are able to make choices about the times for getting up/going to bed, meals and how to spend their time. Residents take their own furniture into the home enabling them to create a home from home environment and can handle their own finances if they wish, although assistance is available in the home. The home employs separate catering staff who provide three full meals per day, which includes a cooked breakfast and three-course lunch. On discussion with residents they stated they enjoyed the meals, received a choice and ample portions. It was stated snacks and drinks are available between meals including supper if they want. The inspector had lunch with the residents and found the meal to be of a good standard, they were hot and tasty. Staff were noted to be attentive to residents providing assistance where required. Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 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 standard(s) 16,18. Feedback indicates that the home is responsive to concerns raised. However, records were not available to demonstrate robustness of the procedures and staff lacked knowledge of some of the procedures for the protection of residents. EVIDENCE: The home has a complaints procedure displayed on the notice board. On discussion with residents they stated they had no complaints, but they were not aware of the complaints procedure. The manger will need to ensure there are systems in place for informing residents of the procedure. At the time of inspection there was one complaint recorded that had initially been forwarded to the Commission. Information obtained during the course of the inspection indicated that concerns had been raised about another matter. There was no record of the action taken. A consumer satisfaction survey undertaken by Laing & Buisson indicated that staff are responsive if any issues are raised. The manger was advised that formal and informal complaints/concerns should be recorded with the action taken and the outcome. On discussion with staff some were not aware of the vulnerable adults procedure and the action to take in the event of an allegation of abuse. This was highlighted at a previous inspection and will need to be addressed through training. Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,23,24,25,26 The standard of décor and furnishings in the home is good, providing residents with a pleasant and homely environment to live. EVIDENCE: Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 16 The home is a modern two-storey building, which is clean, odour free and well maintained. There is adequate parking to the front and a pleasant garden to the rear and side of the building. There is one large lounge/dining room on the ground floor, which has been decorated since the last inspection. It was stated that they hope to have a conservatory built within the coming year. There is a small quiet room on the first, which may be used by residents and staff for meetings etc. There are assisted shower rooms and bathrooms on each floor, enabling residents to have a choice of bathing facilities. All flats are provided with locks and letterboxes to doors; they are carpeted and generally service users provide all their own furnishings, although furniture is available if required. All flats are singly occupied and meet the minimum size requirements. Each flat has an en-suite facility consisting of a toilet and wash hand basin plus a small kitchen area, which has a fridge. A sample of rooms were inspected and were found to be decorated to a good standard, comfortable and personalised. Staff have a master key in the event of an emergency. The home is in the process of providing lockable facilities in each room. Flats are individually and naturally ventilated and windows are provided with restrainers. Radiators are of the low surface temperature type and water from hot water outlets is regulated. The home is in the process of providing covers to pipe work. Laundry facilities were appropriately sited with a washing machine with sluice cycle. Part of the laundry area is segregated to provide sluice facilities. Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Staff morale was good, they were enthusiastic and there was noted to be good relationships between staff and residents. Some further training is required to provide all staff with the appropriate skills. EVIDENCE: The staffing rotas indicated that the manager and assistant manager are on duty plus one senior carer and three care staff. This meets the conditions of registration in respect of minimum staffing levels. It was noted that the home had a number of residents with increased needs since the last inspection. The manager will need to keep this under review, as the home has applied to vary their conditions of registration to enable them to admit residents with dementia. This may lead to an increase in dependency, which would require an increase in staffing levels. A small number of staff files were examined and it was noted on one file that a birth certificate was not available and the reference on another file was not from a previous employer. The deputy manager takes responsibility for the induction training and on inspection it was noted that staff had commenced the training, but it was not being completed within six weeks. Approximately 40 of staff have completed NVQ 2 training and a further 4 care staff are registered to undertake the training. Some staff have undertaken training in respect of caring for residents with dementia. However, this needs to be extended to the remaining staff. Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 18 Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,38 The manager, who is supported by the senior team, provides good leadership with a clear vision for the future. The home is managed in the interests of the residents and their health, safety and welfare is protected. EVIDENCE: The registered manager has recently completed the Registered Managers Award. On discussion with staff they stated the managers were fair, approachable and professional. They felt there was a good working atmosphere and they felt part of a team. There was evidence that residents are consulted about aspects of the home through meetings and on discussion with a number of residents they stated they were happy, one stated “ I would not want to go anywhere else”. On inspection of staff supervision records it was noted that supervision was not consistently undertaken six times per year. Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 20 A sample of records was inspected in relation to maintenance and they were found to be of a generally good standard. Areas that require addressing are evidence to show that the home has addressed issues in respect of the electrical wiring system. Records did not clearly demonstrate that all staff, particularly night staff, had undertaken two fire drills in the last year. The records of weekly fire tests and monthly emergency lighting were not available at the time of inspection. Records of staff training indicated that training in respect of moving and handling was due again. Some staff had not undertaken other mandatory training in respect of basic food hygiene, infection control and first aid. The home has a quality assurance system in place and recently a company has been involved in a customer satisfaction survey obtaining feed back from residents and relatives. The report from this provided very positive feedback and the home scored above the mean for all 37 attributes measured. Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 3 3 3 x x 2 x 2 Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 22 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14 Requirement The registered person must; Ensure assessments are fully completed following admission to the home with appropriate risk assessments covering all areas in standard three of the National Minimum Standards to enable a comprehensive care plan to be drawn up. Where reisdents have dementia a mental health assessement must be completed. Timescale of November 2003 not met. The registered person must ensure all care plans are fully completed and set out in detail the action to be taken by staff to meet service users needs. Where there are any changes or following reviews they must be updated. Staff must review care plans monthly. Timescale of November 2003 not met. The registered person must ensure; The correct administration and recording of medication. Ensure the secure storage of oxygen cylinders. Record the temperature of drug fridge daily. Timescale of Timescale for action 30/8/05 2. 7 15 30/8/05 3. 9 13(2) 25/5/05 Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 23 4. 14 17(2)(4) 5. 16 22 6. 18 13(6) 7. 8. 28 29 18(1) 19 9. 36 18(2) 10. 38 23(4)(d) (e) 11. 38 23(4)(c) November 2003 not met. Ensure all codes are explained; ensure the adminsitration of creams is recorded; where variable doses are prescribed the amount administerd must be recorded; check all medication entering the home for any chnages in doses. The home must maintain up to date lists of all furnishings brought into the home by residents. Ensure the residents or their representative signs the record. Timescale ofJune 2004 not met.. The registered person must introduce a system whereby all residents/representatives are informed of the compliants procedure. The registered person must ensure all staff are aware of the local guidance for responding to any allegations of abuse. Timescale of June 2004 not met. The registered person must ensure at least 50 of care staff are trainined to NVQ level 2. The registered person must ensure evidence of staff identiy such as birth certificate is availble on staff files and references are obtained from the previou employer. The registered person must ensure there are systems in place for staff to be supervised at least six times per year. The registered person must enaure all staff undertake fire training and at least two fire drills each year and records are retained in the home. The registered person must ensure the fire points are checked weekly, the emergency lighting is checked at least once 30/6/05 30/6/05 30/8/05 30/9/05 30/5/05 30/6/05 30/6/05 30/5/05 Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 24 12. 27 18(1) 13. 38 16(2)(j) 14. 38 13(3) 15. 38 13(4) 16. 38 13(4) 17. 38 23 (4) a month and records are retained in the home. Timescale of June 2004 not met. The registered person msut ensure all staff undertake training in respect of caring for residents with dementia commensurate with their position in the home. Timescale of November 2003 not met. The registered person must ensure all staff undertaken training in repsct of basic food hygiene. Timescale of November 2003 not met. The registered person must ensure all staff undertake training in respect of infection control. Timescale of November 2003 not met. The registered person must ensure all staff undertake training in respect of first aid. Timescale of June 2004 not met. The registered person must provide eveidence to indicate the issues in respect of the electrical wiring system have been addressed. Timescale of November 2003 not met. Fire doors should not be propped open. If there is a need to keep them open they must be linked into the automatice fire detection system. Timescale of Decmber 2004 not met. 30/12/05 30/12/05 30/12/05 30/12/05 30/6/05 30/6/05 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. Refer to Standard 12 Good Practice Recommendations It is recommended that an assessment of all residents E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 25 Madeline House 2. 3. 27 past interests and hobbies is undertaken to enable a range of activites to be organised around them. It is recommended that a review of staffing levels for morning shifts is undertaken and this is kept under review taking any necessary action. Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor,Ladywood House 45-56 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 Madeline House E54 S000016912 Madeleine House V225838 050505.stage 4.doc Version 1.30 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!