Inspection on 03/05/05 for Neville Williams House

This inspection was carried out on 3rd 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

Neville Williams House 31/10/07

Neville Williams House 03/01/07

Neville Williams House 21/06/06

Neville Williams House 23/01/06

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 B29 7PP Lead Inspector Karen Thompson Unannounced 03 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. Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Neville Williams House Address 8 Greenland Road Selly Park Birmingham B29 7PP 0121 472 4441 0121 415 5054 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) Broadening Choice for Older People Vacant Care Home 50 Category(ies) of Older People registration, with number of places Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 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 60 and over that require nursing care. 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 Birmingham 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 access to the upper level. Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The findings of the report is based on a statutory unannounced inspection. The inspection was carried out by two inspectors over a 9 hour period. Information for the report was gathered from a number of sources: tour of the building, examination of records and documents, lunch with service users, talking to 4 staff members in addition to the managerial staff, talking to 4 service users direct and indirect observation. What the service does well: What has improved since the last inspection? What they could do better: Care plans must be tailored to meet the service users individual needs and be regularly updated. The nutritional needs of service users must be assessed and all service users must be reassessed for individual wheel chairs. Staff documentation held within the home with regard to recruitment was not comprehensive or robust to protect the service user. Staff do not receive any supervision to discuss their training and personal development in relation to Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 Page 6 meeting service user needs. All staff who manage administration of medication must be assessed as competent on a regular basis and appropriate action taken when their practice falls below the required standard. The complaints procedure must be updated to include that the CSCI can be contacted at any time in the process. The menu choice did not reflect what was served and was rotated on four weekly cycles, which limited choice. The home has a four bedded unit and CSCI are in discussions with the provider as to the future of this unit. 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 v225213 e54 s24870 neville williams v225213 030505 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 Neville Williams House v225213 e54 s24870 neville williams v225213 030505 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 and 4 The information provided for prospective service users needs to be expanded to enable service users to make a fully informed choice. Assessments completed by the home were not comprehensive or able to ensure that service users needs would be met. EVIDENCE: The Statement of Purpose and Service User guide had been recently updated but did not include all information listed in Schedule 1 such as room sizes, registered provider details, visiting policy or arrangements in place for reviewing service users plan of care. A pre admission assessment is undertaken by a competent member of staff and it was noted there was no assessment or reference to falls. Staff interviewed had received recent training in relation to dementia, the exact numbers will be explored at the next inspection. Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 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 standard(s) 7,8,9 and 10.11 There are no clear care plans in place to adequately provide staff with the information they need to satisfactorily meet service users needs. Since the last inspection medicines management has improved but further work is required to ensure that service users are protected by the homes procedure. Service users are treated with dignity and respect. EVIDENCE: Care plans were in place. These were not always comprehensive, detailed or holistic. They were not always reviewed or updated on a regular basis. External healthcare profession advice was sought but not always documented in the service users care plans. The care plans did not sufficiently demonstrate how it would meet specific individual needs. One service user who was assessed as having a high risk of fall, care plan stated “ to be aware when…. mobilising and observe that she does not fall” This statement does not adequately demonstrate how risk will be reduced. Risk assessments were generic and not specific to service user needs. The home has charts in service users bedrooms, which are used to record and monitor service user care but staff are failing to use them to record delivery of care. Charts were noted to be incomplete and out of date. The home is looking to introduce a computerized care planning system as from June this year. The home Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 Page 10 operates a key worker scheme and staff were able to describe how this works. Staff were not always allocated to work in the area where their particular allocated service user was residing. Medicine management had improved since the last inspection but nursing staff still fail to record accurately the administration of medicines in all instances. Robust systems to check the dispensed medication into the home had not been fully implemented. Managerial staff had completed various audits but these had failed to identify the nurse responsible for incomplete recording or the mal-administration of medicines. The home lacked written protocols for “when required” occasional use medicines and did not risk assess service users who wished to self-administer their own medication or undertake compliance checks. Cream management was noted to be poor within the home. An Oxygen cylinder was not chained to the wall even though facilities were available to do this. Another oxygen cylinder was found in a double bedroom, the service user who had used this had vacated the room some time back and the cylinder should have been returned to the pharmacist. Service users felt they were treated with respect and their right to privacy was upheld. Service users clothes were nicely launder and the home staff will carry out minor repairs to clothing such as replacing a button or re hemming. A public telephone was available but it was located in a communal area and therefore was not private. Screening was available in shared rooms. Staff need to be more attentive to maintaining service users dignity. One service users dress was not place underneath them when being helped to sit down, so when they were assisted from the chair their undergarments were revealed. The home needs to develop a cross gender intimate care policy. The home has implemented a resident diary for family members, the appropriateness of some of the entries made by staff was discussed with the Care Manager, who will address this with staff. Staff were able to demonstrate a compassionate approach to the care of the dying and their wishes being carried out. Documentation was seen in relation to one service users wishes in the event of death. The home needs to develop a systematic approach to demonstrate that it has discussed such matters with all service users or their representative. Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 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 standard(s) 12 and 15 Social activities provided in the home were limited and not all the service users leisure /activities needs are catered for. The meals provided are good, plentiful and cater for dietary needs but the menus do not offer an alternative for service users to exercise choice. EVIDENCE: Saints’ days and Christian festivals are celebrated in addition to service users birthdays within the home. The home does not have an activities co-ordinator. Service users spoke of few activities taking place generally within the home other than musical events. On the day of inspection a movement to music session was taking place within the home. Individual social needs of service users are not met in all instances. Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 Page 12 The meals served in the home were nutritious, wholesome and well presented. Portions were generous and “seconds,” offered. The home offered catered for special dietary. Breakfast was highly praised and the open choice system appreciated. Choice for lunch and teatime was limited to a four weekly menu that was rotated on a four weekly basis. Service users advised the inspector that on becoming resident at the home they choose their four week menu and this was their chose until the menus changed again, and for half the year the diet was fixed until the new menu came out. On the day of the inspection the menu choice did not reflect what was served for both the main course and dessert. Service users felt that a weekly menu that reflected the meals served and an improved teatime menu would improve the service. Service users advised the inspectors that tea time meals were monotonous and mainly considered of sandwiches. Staff were seen to offer assistance to service users in a discreet manner but this was not seen in all instances. Observation of breakfast assistance demonstrated good practice. Lunchtime practice was mixed, with service users not being correctly positioned initially to eat their meal, staff appeared hurried and did not sit down to offer appropriate support. Staff assist service users by standing up and lean over them which was not appropriate. Service users are able to choose where that wished to eat their meals. Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 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 standard(s) 17 and 18 Service users legal rights are protected and staff in the home are familiar with adult protection procedures. EVIDENCE: The complaint leaflet did not include that the Commission for Social Care Inspection could be contacted at any time by a complainant and the correct telephone number needs to be inserted. Voting cards were observed in the home for service users. The Care Manager was able to demonstrate good knowledge in relation to adult protection procedure via liaising with social services. The written procedure in the home needs to be amended to reflect the local multi-agency guidelines that staff should follow in the event of an adult protection concern. Staff spoken to had either received adult protection training from the organisation or as part of their NVQ training. The home at present is not doing POVA checks on potential application, CRB done, this means there is a weakness in their protection of vulnerable adults. Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 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 standard(s) 19,20,21,23,24,25 and 26 Service users live in a well-maintained environment which meets their needs and have access to good indoor and outdoor facilities. Health and safety concerns are in the main addressed but further attention is required to ensure that they are comprehensive and provide service users with a safe living environment. EVIDENCE: The home was well maintained and had a rolling programme of redecoration. At the time of the inspection the ground floor lounge and dining room was in the process of being redecorated. The home was built a number of years ago but was built to high specification. The garden was well maintained and fully accessible for service users who use wheel chairs or have other mobility problems. The home was currently purchasing some additional garden seating. Many bedrooms have en suite facilities with showering facilities. One assisted bath with hoist was seen. The four-bedded unit does not meet the standards 23.and discussion with the organization and CSCI will be taking place in Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 Page 15 regards to this. The bedrooms were individualised with personal belongings, clean and well presented. Bedrooms did not contain all the furniture listed in standard 24 the home will need to discuss with service users or their representatives as to the provision of this furniture and document this discussion. If rooms can not accommodate all the furniture listed in standard 24, then the home statement of purpose must detail these rooms. No bedrooms were carpeted, but rugs were provided if risk assessed as safe for the service users. All the corridors were fully carpeted and the home was free from offensive odours. Numerous light bulbs were not working in the home and had not been replaced. This left some rooms relatively dark. The home did not have thermostatic controlled valves fitted to water hot outlets temperatures were noted to be above 43c, which could cause scalding. This matter must be addressed with some urgency. The home is awaiting its legionelle testing certificate to demonstrate compliance. The inspectors were unable to find evidence of hot water boiler temperatures being recorded. At the time of the inspection some soap dispensers and alcoholic rub dispensers were empty and had not been replaced. Service users clothes were well-laundered service users well presented. The home has a systematic approach to laundering clothes and this was observed to be of a high standard. There were adequate systems in place to deal with infected laundry. Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 Page 16 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 and 29 Staffing levels in the home are not maintained at levels previously set which the home is required to comply with resulting in service users having to wait for staff assistance on occasions. Staff files do not demonstrate sufficient checks are in place with regard to a robust recruitment process to safe guard service users. EVIDENCE: Staff rotas were seen for the forthcoming month and did not indicate when the managerial staff would be on duty. There are a number of vacancies of care staff and the home is liaising with agencies to provide adequate support. The home only planned to have one trained nurse on of a night time duty and the minimum staffing requirement issued by the health authority is that two qualified nurses are on duty throughout the day and night. Agency staff are given a handover sheet which gives a brief outline of service user medical conditions and additional care staff are on duty at peak times in the morning within the home. Service users interviewed during the inspection said that staff could take up to half an hour to answer their call bell. The staff files sampled during the inspection did not demonstrate that Schedule 2 (Care Standards Act 2000) had been adhered to. Two written references had not been routinely sought prior to the appointment of staff. The last employer had not always been contacted and relevant police checks could not be evidenced. These records are held at the head office and were not available for inspection. All staff do receive a probationary period and a statement of terms and conditions. Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 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 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) 31,35,36 and 38 The manager was able to demonstrate that safeguards are in place in relation to service users finances and documentation in relation to health and safety was good ensuring that service users and staff are protected. The home does not undertake staff supervision and fails to identify staff training and personal development needs in relation to meeting service users needs EVIDENCE: The Care Manager is in the process of completing a recognised management qualification and has submitted an application in relation to being the Registered Manager. The homes policies and procedures regarding service users’ money and financial affairs were robust and fully auditable. Service users money had comprehensive records for all transactions. The majority of the service users depend on the management to administer their personal allowance to them. Personal allowances not spent were returned to the family at regular intervals. No staff were receiving supervision or had opportunities to discuss their work performance or training needs and this must be addressed. Staff interviewed Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 Page 18 had received recent training in relation to dementia, the exact numbers will be explored at the next inspection. Documents examined in relation to the health and safety of the home was available. The majority of staff had only received one fire lecture each year which should be increase to at least two occasions each year with records maintained accordingly. Three staff members were noted not to have received any training in the past year. The fire log was completed on a weekly basis. Evidence of the five yearly worthiness of electrical system is not available for the home until identified work is completed. Plans are in hand for this work to be done. Staff interviewed have received training in first aid, food hygiene and manual handling. The home has in house trainers in relation to manual handling training. Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 2 2 2 3 STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x 3 2 x 2 Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 Page 20 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 1 & 24 Regulation 4 Sch 1 Requirement The Registered Person must ensure that the Statement of Purpose and Service User guide is up to date and contains all the information listed in the schedule. The home must ensure that it provides private accomodation for each service user that is furnished and equiped as stated in the minimum standards and if it is unable to do so due to limitiation of space them these bedrooms must be identified in the Statement of Purpose The Registered Person must ensure that the pre admission assessment assess risk of falls. The Registered Person must ensure that care planning is based on a comprehensive assessment and that individual needs are identified, monitored reviewed regularly. The Registered Person must ensure that multi professional health care visits are documented in the service users care plan and any change to care are recorded. The Registered Person must Timescale for action 10th July 2005 2. 3. 3 4&7 14(1a) 15(1&2) 10th July 2005 10th August 2005 4. 8 10th July 2005 5. 8 12(1a) 10th July Page 21 Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 13(1b) 6. 8 12(1a) 13(1b) 7. 9 13(2) ensure that it undertakes nurtritional assessments to ensure that dietary needs are being met. The Registered Person must ensure that it undertakes a continence assessment to ensure that service users management of continence is promoted. The Registered Person must ensure that robust systems must be installed to check the prescribed and dispensed medication received into the home. Regular staff drug audits must be undertaken before and after a drug round to demonstrate nursing staff competence in medicine management. Outstanding requirement from 12/11/04 The Registered Person must ensure that all service users wishing to self administer their own medication must be risk assessed as able and compliance checks undertaken on a regular basis. The Registered Person must ensure that protocols for the use of “when required” medication must be written to reflect the prescriber’s wishes and reviewed on a regular basis. The Registered Person must ensure that all creams must be dated once opened and discarded after 28 days to reduce the risk of microbial contamination and must be used for the service user they are prescribed for only. 2005 10th August 2005 10th June 2005 8. 9 13(2) 10th June 2005 9. 9 13(2) 10th June 2005 10. 9 13(2) 10th June 2005 Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 Page 22 11. 9 13(2) 12. 10 12(4)a) 13. 10 12(4)a) 14. 10 12(4)a) 15. 11 12(1-4) 16. 12 16(n) 17. 15 16(2i) 18. 15 16(2i) 19. 15 12(4a) The Registered Person must ensure that oxygen cylinders are stored appropriately when not in use The Registered Person must ensure that service user can make and recieve telephone calls in private The Registered Person must ensure that all staff are aware that service users clothing is appropriately positioned to protect their dignity and this become practice within the home The Registered Person must ensure that the home has a cross gender initimate care policy and staff are familiar with it. The Registered Person must ensure that serviced users wishes in relation to death and dying are discussed , documented and carried out. The Registered Person must ensure that they consult with service users about the programme of activities arranged by or on their behalf of the care home and provide facilities for recreation incuding having regard to the needs of service users The Registered Person must consult with service user with regards to meals and menu choice to ensure that a review of the present arrangements takes place. The Registered Person must ensure that the menu is an accurate reflection of what is being provided at meal times. The Registered Person must ensure that staff provide service users with discreet, unhurried and appropriate assistance 10th June 2005 10th September 2005 10th June 2005 10th August 2005 10th September 2005 10th September 2005 10th August 2005 10th July 2005 10th June 2005 Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 Page 23 20. 15 12(1a) 21. 16 22 22. 18 13(6) 23. 24. 25. 18 23 25 13(6) 12 17(3b) 26. 25 13(4c) 27. 25 13(4c) 28. 26 13(3) 29. 27 18(1a) The Registered Person must ensure that service users are correctly positioned at the being of a meal to enable to eat and digest their food. The Registered Person must ensur that the complaints procedure is simple and clear to support the home to ensure that complaints are dealt with promptly and effectively The Registered Person must review its adult protection procedure to ensure that it compiles with local guidlelines The Registered Person must ensure that all staff have a POVA check completed. The Registered Person should forward plans in regards to the multioccupancy room The Registered Person must ensure that the Legionelle testing is sent to the Commission once obtained. This is an outstanding requirement from 30/09/04. The Registered Person must ensure that boiler temperatures are periodic taken and are within the range of 60c The Registered Person must ensure that thermostatic control valves are fitted to water outlets that service users have access to. The Registered Person must ensure that liquid soap is available to allo staff to wash their hand and prevent the spread of cross infection., The Registered Person must ensure that minimum stafffing levels are maintained at all times though out the day and night and the complement of trained to untrained is as previously required by the health authority.. 10th June 2005 10th July 2005 10th July 2005 10th July 2005 10th July 2005 10th June 2005 10th July 2005 10th September 2005 10th June 2005 10th September 2005 Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 Page 24 30. 31. 29 31 Sch 2 10(3) 32. 36 18(1ci) 33. 38 13(4e) 34. 38 23(4e) 35. 38 23(4) The Registered Person must audit staff files to ensure they comply with Sch 2 The Registered Person must ensure that the manager achieves a recognised qualification by 2005 The Registered Person must ensure that all staff have supervision and this is recorded and take place a minimum of six times a year. The Registered Person must ensure that the five year electrical wiring test certificate is obtained and forwarded to the Commission. Outstanding requirement from 30/9/04 The Registered Person must ensure that all staff attend and complete two fire lectures per year. The Registered Person must increase frequency of fire drill so all staff are aware what to do during the procedure. 10th September 2005 10th September 2005 10th September 2005 10th June 2005 10th June 2005 10th June 2005 36. 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 Good Practice Recommendations Neville Williams House v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Birmingham and Solihull Local 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 v225213 e54 s24870 neville williams v225213 030505 stage 4.doc Version 1.30 Page 26 - 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!