Inspection on 23/01/06 for Neville Williams House

This inspection was carried out on 23rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Neville Williams House 31/10/07

Neville Williams House 03/01/07

Neville Williams House 21/06/06

Neville Williams House 03/05/05

Neville Williams House 12/11/04

Neville Williams House 21/07/04

Neville Williams House 15/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Neville Williams House 8 Greenland Road Selly Park Birmingham West Midlands B29 7PP Lead Inspector Elizabeth Mackle Unannounced Inspection 10:00 23 January & 3 February 2006 rd rd 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 Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Neville Williams House Address 8 Greenland Road Selly Park Birmingham West Midlands B29 7PP 0121 472 4441 0121 415 5054 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) Broadening Choices for Older People Vacant Care Home 50 Category(ies) of Dementia (50), Old age, not falling within any registration, with number other category (50) of places Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th November 2004 Brief Description of the Service: Neville Williams House is a large 2-storey purpose built home that provides 50 beds for service users aged 65 and over that require nursing care. The building is to a high specification and meets the Care Homes Regulations 2001. It is decorated to a very high standard and is well maintained throughout. The home is set in a quiet residential area of Selly Park, within easy access to bus routes. There is a car park to the front of the home and a large secure, private garden to the rear of the building. The home is owned and operated by Broadening Choices for Older People, a local charity whose head office is based in Harborne, Birmingham. Neville Williams offers 42 single en-suite rooms, 2 double en-suite rooms and a 4 bedded high dependency ward area. There are lounges and dining rooms situated on both floors, with a passenger lift for disabled access to the upper level. Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and carried out by one inspector over two days (23 January 2005 and 3 February 2006) and included the investigation of a complaint. Information for the report was gathered from a number of sources including: a partial tour of the premises, examination of a variety of records and documents, talking with three residents, discussions with five staff members in addition to managerial staff, and direct and indirect observation. This was the second statutory inspection of 2005/2006 and this report should be read in conjunction with the report of the Unannounced Inspection carried out on 3rd May 2005. What the service does well: What has improved since the last inspection? What they could do better: Care plans must be sufficiently detailed in relation to how identified care needs are to be met, they must reflect current care needs and be subject to regular review and updating. The nutritional needs of residents must be properly assessed and the residents’ weight monitored on a regular basis. Where records of a resident’s fluid intake are required these must be fully maintained. The recording of complaints needs to be more thorough, and the complaints procedure must be updated to include that CSCI can be contacted at any time throughout the process. Recruitment practices are not sufficiently robust to ensure that residents are protected. Records must be maintained to demonstrate that all registered nurses have current registration with the Nursing and Midwifery Council and Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 6 have undergone Criminal Records Bureau and Protection of Vulnerable Adults Register checks. It is essential that all staff undergo statutory training at relevant intervals. There is a need to appoint a registered manager for the home. 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. Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Prospective residents have most of the information they need in order to make an informed choice about admission to the home. EVIDENCE: The home has a comprehensive Statement of Purpose and Service Users Guide which includes information such a description of the services provided, a Residents Charter of Rights, information on staffing, a copy of the latest Commission for Social Care Inspection report and other relevant information. Although the document has been partially revised since the last inspection, more updating is required to reflect all the information required in the Schedule. Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 The care planning system is not sufficiently robust to provide staff with all the information they need to meet the needs of residents. Information in relation to resident’s weight and fluid intake is not systematically recorded so that it is unclear whether residents’ nutrition and hydration needs are being fully met. Residents are treated with respect and sensitivity. Residents and their families are benefiting from the home’s participation in the Gold Standards Framework in Palliative Care. EVIDENCE: The health care records of three residents were sampled. Care Plans were viewed and found to be not specific enough in relation to details of identified care needs, details of care interventions required, and how the stated aims were to be met. One diabetic resident had a nursing intervention recorded within the care plan as “check blood sugar as required”, but no indication of frequency, what the normal range was, or what action was to be taken if levels fell outside this. In the case of another resident it was unclear how frequently wound dressings were to be changed or what solution was to be used. The care plan did not evidence that the dressings had been changed at frequent intervals. There was evidence within the records of some appropriate risk assessments having been carried out, such as Falls Risk Assessment and Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 10 Manual Handling Risk Assessment. Care plans were found to be out of date in relation to current care needs, and there was no system of regular review and updating of care plans to reflect changing needs of the resident. There did not seem to a uniform approach regarding the regular weighing of residents and in the case of one resident no evidence that her weight had been monitored and recorded for a period of time, in spite of a history of weight loss. Other areas of concern identified included shortcomings in the use of Nutritional Risk Assessment tools, and failure to keep detailed records of food and fluid intake where required. Residents generally appeared to be clean, comfortable and appropriately dressed. In the case of one resident who was being nursed in bed it was disappointing that drinks had been placed in such a way that she was unable to reach them. A useful assessment tool had recently been developed by nursing staff to assist with decision making about residents administering their own medication and three residents were managing their own medication. Residents have access to a lockable facility in their bedrooms, if they are assessed as able to selfadminister medication. Protocols had not yet been developed for the use of “when required” medication. Staff were observed to be treating residents with respect and in a caring and courteous manner. A cross gender intimate care policy has still to be developed. The home is taking part in a new national programme (in association with John Taylor Hospice) – The Gold Standards Framework is Palliative Care for Care Homes Pilot. This has generated much interest amongst staff and they believe has resulted in an improvement in the clinical care they offer to the people who are dying and support to their families. Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 Social and recreational activities in the home were limited and not all the needs of residents for such activities are being met. Residents were encouraged to maintain relationships with families and friends, offering them valuable support. The meals provided are of a good standard and offer choice and variety to residents. EVIDENCE: There is at present no Activities Organiser within the home. Until last year a part-time (6 hours a week) activities organiser had been employed and this function had not been replaced when the employee left. The annual programme of events showed such activities as: Weekly Salvation Army band, Carols at Christmastime, an annual “clothes show” and “Mr Motivator” attending weekly. The company had introduced a quarterly Neville Williams Newsletter in October 2005 with the aim of informing residents, families and staff about matters of interest. This was found to be both informative and easy to read, and included information such as forthcoming events, staff news, and resident’s birthdays. The Newsletter also contained form on which readers could record their comments and suggestions about future topics. Feedback had been very positive and some relatives had also suggested a regular feature giving a short Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 12 profile on the interesting lives of residents. It is planned to incorporate this idea into future copies of the Newsletter. The arrangements for provision of catering service had recently passed to an outside company. Although some difficulties had been experienced with the new provision, staff were confident that issues they had raised were being addressed. A four weekly cycle of menus is in operation, and the Catering Manager confirmed that the menus were currently in the process of being reviewed. Residents could chose between two options for the lunch and evening meal, and there was a good supply of fresh vegetables. Fridge and freezer temperature records were viewed and found to be in order. Cleaning schedules were found to be incomplete and the frequency of cleaning activity within the kitchen was not clear. Staff were observed to be offering residents assistance with eating in a discreet and sensitive manner. There were no rigid routines within the home and relatives and friends were encouraged to visit without restrictions. Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The handling and recording of complaints needs to be improved to ensure that the concerns of residents, their families and others are listened to and acted upon. EVIDENCE: The complaints register was viewed and found to be incomplete in respect of known recent complaints. One complaint had been recorded since the previous inspection regarding catering. Where complaints were recorded there was a lack of detail such as information about any investigation undertaken, any action taken, and whether this has been made known to the complainant. One complaint had been received by the Commission for Social Care Inspection. The allegation was that a resident had become dehydrated due to fluids not being given at the home. The CSCI investigation partially upheld the complaint, as the home was unable to fully evidence from the written records that the resident had been given all necessary fluids. BCOP have a comprehensive policy on the handling of complaints and have also produced a shorter version in the form of a leaflet entitled “How to Complain”. Both these documents need to be updated to reflect that the complainant may refer the complaint to the Commission for Social Care Inspection, at any stage in the process, should they wish to do so. The written adult protection policy in the home needs to be updated to reflect the local multi-agency guidelines to be followed by staff in the event of an adult protection concern. Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 14 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): These standards were not assessed on this occasion. EVIDENCE: Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Staffing levels in relation to registered nurses were not maintained at levels previously set, and this may result in difficulty meeting the nursing care needs of residents. The home’s records did not evidence that sufficiently robust recruitment and training procedures were in place to safeguard residents. EVIDENCE: Staffing rosters were viewed in relation to registered nurse cover and indicated that two Registered Nurses were on duty during the day. There is still only one registered nurse on duty at night. The “Lead” clinical nurse conducts preadmission assessments, which can take her out of the home for a number of hours at a time and this may result in only one qualified nurse being available in the home. The minimum staffing requirement issued by the health authority is that two qualified nurses are on duty throughout the 24-hour period. Given the complex care needs of many of the residents, the Commission is not confident that these could be properly met and documented, by one nurse alone. A member of the administrative team was drawing up the duty roster for nursing and care staff. Seven staff files were viewed. Recruitment practices were found not to be satisfactory. References had not always been obtained and where they were available it was often the case that referees were work colleagues and had not known the applicant in a managerial or supervisory capacity. The files did not contain evidence that Criminal Records Bureau and Protection of Vulnerable Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 16 Adults Register checks had been carried out. Where one member of staff had moved from “bank” to a “permanent” position, the records were incomplete. The files did not always include copies of Job Description or evidence that new staff received planned and appropriate induction training. There was no system in place for keeping records of Nursing and Midwifery Council periodic registration for nurses. Checks had been made at the time of appointment but at the time of the inspection it appeared that the Nursing and Midwifery Council registration of some nurses was out of date. Some information pertaining to staff was computerised but the home had obtained a Staff Register and the plan was to move to recording manually in the near future. The Training records were viewed, and found to be clear and concise detailing the timetable of training for the year 2006. However records did not demonstrate that all staff were up to date in respect of statutory training. In relation to fire training the records indicated that a number of staff had not received training, although the assistant manager said they had, and this had not yet been entered. It was nevertheless the case that the records indicated that a number of staff had not attended various statutory training for more than one year. Nine care staff were scheduled to undertake training in Infection Control at Bourneville College during the year. Other training available to staff included: Health and Safety, First Aid, Food Hygiene, Fire awareness, Manual Handling, Appraisal Training. Dementia Management, Prevention of abuse, Cultural Awareness, Wound Management, and Leg Ulcer Management. Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36 The absence over a long period of an identified Registered Manager in the home has resulted in a lack of clarity amongst staff about who has overall management responsibility. The home has begun to implement systems for consultation with residents in the home to ensure that their views are canvassed and acted upon. EVIDENCE: The Home has had no manager in post since July 2005. Interim arrangements in place are that two existing members of staff (one staff nurse and the assistant manager) carry out a range of management duties in addition to their existing roles. The staff nurse works two days a week as “clinical lead nurse”, in a supernumerary capacity but does not have general management responsibility for the other registered nurses. The rest of the week she works as a staff nurse and retains “named nurse” responsibility for 15 residents. The assistant manager’s management responsibilities includes drawing up the staffing roster (including for nursing staff), and functions such as Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 18 housekeeping, laundry and liaising with the catering company. There is lack of clarity about lines of accountability within the home and this has resulted in a situation in which some staff were unclear about who has overall management responsibility. One member of staff said “Things are improving; we work as a team. “It would be good if one manager was appointed.” Staff had received a letter from the company outlining the interim management arrangements towards the end of 2005. The assistant manager attends regular monthly meetings with senior BCOP staff. The Lead Nurse holds weekly meetings with nurses in the home to improve communication, but no minutes are kept of these meetings. The home has engaged the services of an external Quality Assurance consultant and work has commenced towards developing quality monitoring systems within the home. Initial meetings had been held, and a Consumer Survey Questionnaire had been circulated to relatives with the first edition of the Newsletter; information from this was in the process of being collated. Internal Quality Assurance questionnaires had recently been circulated to residents and members of staff. This work is ongoing. There was no system of formal supervision of staff. Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 2 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 2 X X 1 X X Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Sch 1 Requirement The Registered Person must ensure that the Statement of Purpose and Service User guide is fully updated to contain all the information listed in the Schedule. Outstanding Requirement from last inspection - May 2005. The Registered Person must ensure that the pre-admission assessment includes an assessment of risk of falls. This requirement was not assessed for compliance on this occasion. The Registered Person must ensure that there is a robust care planning system in place so that staff have all the information required to meet the needs of residents. This must include details of individual needs identified, details of care interventions required, and how the stated aims are to be met. Care Plans must be frequently reviewed and updated to reflect any changes in the resident’s DS0000024870.V281953.R01.S.doc Timescale for action 01/05/06 2 OP3 14(1)(a) 01/04/06 3 OP7 15(1)(2) 04/02/06 Neville Williams House Version 5.1 Page 21 4 OP8 12(1)(a) 5 OP8 12(1)(a) 13(1)(b) 6 OP8 15(1)(2) 7 OP9 13 (2) 8 OP10 12 (4) (a) 9 OP11 12(1,2,3, 4) condition. A Requirement in relation to care planning was made at the last inspection – May 2005. The Registered Person must ensure that nutritional assessments are undertaken to make certain that dietary needs are being met. This requirement was not fully assessed for compliance on this occasion. The Registered Person must ensure that continence assessments are undertaken to ensure that service users management of continence is promoted. This requirement was not assessed for compliance on this occasion. The Registered Person must ensure that health care needs of residents are fully met, particularly in relation to the monitoring and recording of weight and fluid intake. The Registered Person must ensure that protocols for the use of “when required” medications are written to reflect the wishes of the prescriber and reviewed on a regular basis. Outstanding requirement from the last inspection – May 2005. The Registered Person must ensure that the home has a cross gender intimate care policy and that staff are familiar with it. Outstanding requirement from the last inspection – May 2005. The Registered Person must ensure that the wishes of service users in relation to death and dying are discussed, documented DS0000024870.V281953.R01.S.doc 01/04/06 01/05/06 01/04/06 01/04/06 01/05/06 01/05/06 Neville Williams House Version 5.1 Page 22 10 OP12 16(n) 11 OP12 16(2)(j) 12 OP14 12 (4)(a) 13 OP15 16(2)(i) 14 OP16 22 (2) and carried out. This requirement was not assessed for compliance on this occasion. The Registered Person must consult with residents about the range of activities they would wish to have available, and provide a structured programme of activities. Outstanding requirement from the last inspection – May 2005 The Registered Person must ensure that records are maintained to confirm that cleaning within the kitchen is carried out at appropriate intervals. The Registered Person must ensure that the home has a cross gender intimate care policy and that staff are familiar with it. Outstanding requirement from the last inspection – May 2005 The Registered Person must consult with service users with regard to meals and menu choice to ensure that a review of the present arrangements takes place. This requirement was not assessed for compliance on this occasion. The Registered Person must ensure that the Complaints procedure and “How to Complain” leaflet are updated to include the correct name of the regulatory body, the telephone number, and the information that the complainant may involve Commission for Social Care Inspection at any stage. The Registered Person must ensure that all complaints are DS0000024870.V281953.R01.S.doc 01/06/06 01/04/06 01/06/06 01/06/06 01/04/06 14 OP16 22(3)(4) 01/03/06 Page 23 Neville Williams House Version 5.1 recorded, including details of investigation and any action taken. 16 OP18 13(6) The Registered Person must review the adult protection procedure to ensure that it complies with local guidelines. Outstanding requirement from the last inspection – May 2005. The Registered Person must ensure that all staff have enhanced Criminal Records Bureau checks done before commencing employment. A requirement in relation to POVA checks was made at the last inspection – May 2005. The Registered Person should forward plans to CSCI in respect of multi-occupancy room. Outstanding requirement from the last inspection – May 2005. The Registered Person must ensure that boiler temperatures are periodically taken and are within the range of 60c. This requirement was not fully assessed for compliance on this occasion. The Registered Person must ensure that thermostatic control valves are fitted to water outlets that service users have access to. This requirement was not fully assessed for compliance on this occasion. The Registered Person must ensure that minimum staffing levels are maintained at all times, as previously required by the health authority. Outstanding requirement from the last inspection – DS0000024870.V281953.R01.S.doc 01/03/06 17 OP18 13(6) 04/02/06 18 OP23 12 01/06/06 19 OP25 13(4)(c) 01/05/06 20 OP25 13(4(c) 01/05/06 21 OP27 18 (1) (a) 01/04/06 Neville Williams House Version 5.1 Page 24 22 OP29 19 Sch 2 23 OP29 19 Sch 2 24 OP30 18(1)(c) 25 OP30 18(1)(c) May 2005. The Registered Person must ensure that recruitment practices are strengthened particularly in relation to obtaining satisfactory references, and carry out an audit of staff files to ensure that they comply with Schedule 2. Outstanding requirement from the last inspection May 2005. The Registered Person must ensure that all nurses have current Nursing and Midwifery Council Registration, and implement a system for the ongoing monitoring of this. The Registered Person must ensure that all staff receive appropriate induction training within six weeks of appointment of their posts. The Registered Person must ensure that all staff attend and complete two fire lectures per year. This is an outstanding requirement from the last inspection – May 2005 The Registered Person must ensure that staff receive statutory training (First Aid, Health and Safety, and Moving and Handling) at the appropriate intervals and that up to date records of this are maintained. The Registered Provider must ensure the appointment of a Registered Manager. The Registered Person must ensure that the registered manager communicates a clear sense of direction and leadership. 01/03/06 04/02/06 01/04/06 01/03/06 26 OP30 18 01/06/06 27 28 OP31 OP32 8 8 01/07/06 01/08/06 Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 25 29 OP36 18(1)(c) (i) The Registered Person must ensure that all staff have supervision a minimum of six times a year, and that records of this are maintained. This requirement is outstanding from the last inspection – May 2005. 01/07/06 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 OP32 Good Practice Recommendations The Registered Person should institute regular meetings with staff to ensure effective two-way communication. Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 Page 26 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 Neville Williams House DS0000024870.V281953.R01.S.doc Version 5.1 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!