Inspection on 19/07/05 for Olivet Christadelphian Care Homes

This inspection was carried out on 19th July 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

Olivet Christadelphian Care Homes 14/08/08

Olivet Christadelphian Care Homes 05/09/06

Olivet Christadelphian Care Homes 30/11/05

Olivet Christadelphian Care Homes 07/01/05

Olivet Christadelphian Care Homes 15/06/04

Olivet Christadelphian Care Homes 17/02/04

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 Olivet Christadelphian Care Home 17 Sherborne Road Acocks Green Birmingham B27 6AD Lead Inspector Amanda Lyndon Announced 19 July 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. Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Olivet Christadelphian Care Home Address 17 Sherborne Road Acocks Green Birmingham B27 6AD 0121 683 8700 0121 683 8701 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) Christadelphian Care Homes Mrs Margaret Maylin Care Home 60 Category(ies) of Care Home with nursing registration, with number Old age, not falling within any other category of places Dementia- over 65 years of age Physical disability over 65 years of age Terminally ill over 65 years of age Sensory impairment over 65 years of age Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of beds is 60, of which 31 may be for nursing care and 29 for residential care. 2. Males and females over the age of 65 years. 3. That one named service user under the age of 65 can be accommodated and cared for within this home for reasons of old age. Date of last inspection 7 January 2005 Brief Description of the Service: Olivet provides nursing and residential care for up to 60 persons of 65 years of age or above and the service is exclusively offered to those of the Christadelphian faith. The home is situated on a site that also provides sheltered housing and operates as part of the Christadelphian Nursing and Residential Care Organisation and has other establishments around the country. There is sufficient off road parking for 27 vehicles as well as a dedicated space for the visiting GP. The home has an attractive enclosed garden area to the rear of the property, which service users have access to. The premises are close to public transport links to the city centre and within walking distance of a range of local amenities. Nursing and residential areas are located in separate wings of the building; the nursing area is a recent build and has a dedicated section for care of those suffering from dementia. The home has three shared rooms with en-suite facilities. The remaining single rooms, with the exception of one room have ensuite facilities and these have recently been upgraded to include a walk in shower facility. Each wing has a lounge and there are a number of dining and bathing areas, the home also has on site kitchen and laundry facilities. Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection was undertaken by three Inspectors, including the Pharmacy Inspector during a full day, and were assisted throughout by the Registered Manager. On the day of the inspection there were 55 people living at the home, 30 residents receiving nursing care and 25 residents receiving residential care. Information was gathered from speaking with the residents, staff and relatives, observing the care staff performing their duties, the pre inspection questionnaire and examining care, medication and health and safety records. Prior to the inspection 8 comment cards were received by the CSCI about the service provided at Olivet and all of these were very positive in nature, including comments such as “ The home provides care with respect ensuring the dignity of the residents at all times” and “ It is always a pleasure to visit this home”. What the service does well: Residents are well supported by the nursing and care staff to meet their health, welfare and personal care needs and are cared for in a respectful manner. The staff monitor any treatments prescribed by the Doctors to ensure that the residents’ health problems are improving. The medicine management on the residential was good and the manager was keen to improve practice further. “ We cater for the spiritual needs of the residents living here and there are good friendships between residents living at the home because of this” There is a wide variety of activities on offer at the home for the residents to participate in and residents are able to exercise choice over their daily lives and the activities that they choose to participate in which promotes their individuality and independence. One resident said “ I prefer to stay in my room and can have my meals in my room if I want to, and I have quite a few visitors”. There are good links maintained with the Christadelphian community. One resident said, “ We are a very close community here and I have met again many friends from the past since coming to live here” Residents receive a wholesome and nutritious diet which meets any dietary needs. One resident said, “ The meals are fabulous here and we have a choice of meals”. Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 Stage 4.doc Version 1.30 Page 6 Olivet provides an attractive, homely, comfortable and clean environment for residents to live in and visitors are made to feel welcome. One resident said, “ It’s all kept beautifully clean here. I don’t have to ask for my room to be cleaned as it’s always cleaned”. Agency staff are not used and there is a stable workforce and this ensures continuity of care, and appropriate training is arranged for the staff team to ensure that they have the appropriate knowledge to work competently within their job roles. One resident said, “ I’ve lived here for over two years and I find all the staff to be very nice”. The Welfare Committee meet with residents regularly to discuss the service provided. Senior managers visit regularly to ensure that the standard of service provided at Olivet is of a high standard. All of the equipment used is checked regularly to ensure that it is safe to use. 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. Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 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 Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 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) 3 & 5 The assessment and admission processes are comprehensive and this ensures that the prospective resident has all relevant information about Olivet and that individual care needs can be met. EVIDENCE: Pre admission assessments are undertaken by senior staff for all prospective residents who have expressed an interest about coming to live at the home, using a comprehensive assessment document. Prospective residents and their families are encouraged to visit the home and have a meal with other residents. One resident said “ I only moved in here a few weeks ago but I am already very happy and settled”. Residents come to live at the home with a trial period of one month, however the duration of this could be negotiable dependent on individual cases. Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 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 & 10 Residents’ ongoing health and personal care needs are well met and any health concerns are monitored by the home’s staff, however the care planning system does not always reflect the current care regime to be provided and this may prevent the appropriate care being afforded to that person. The medicine management on the residential unit was good and the assistant manager was keen to implement further good practice. The medicine management on the nursing unit did not match the high standard seen on the residential unit and further work is required to ensure the service users receive the medicines as prescribed and are documented accurately. Residents are supported in a respectful manner by the staff and this ensures that the residents’ dignity and self-esteem are maintained. EVIDENCE: Comprehensive assessments are undertaken for residents on admission to the home and there was evidence that this was discussed with a person receiving residential care at the home. Care files identified that residents were receiving a high standard of care meeting both their health and personal care needs however the staff were using the daily reporting system to convey information about the residents’ Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 Stage 4.doc Version 1.30 Page 10 holistic care needs instead of the individual care plans and subsequently any specific information that nursing staff or visiting Health Care Professionals may require was not always readily accessible without reading through an excess of daily reports. Personal risk assessments had been undertaken including the risk of falls; tissue viability and comprehensive moving and handling risk assessments had been undertaken. Comprehensive documentation in respect of urinary catheterisation was maintained and wound care provided was recorded in detail. Care plans and risk assessments had not always been reviewed monthly and evaluations did not include a written review of the care needs. Care plans had not always been updated and therefore did not always identify the current care regime In addition, care plans were not agreed or reviewed with the involvement of the residents and/or their relatives. Care plans for acute health care needs were not always written, however there was written evidence within the care file that these needs were being met. “Core” care plans are used and these had not always been personalised to identify the resident’s individual care needs. Daily reports were written in very good detail and identified the activities that the resident had engaged in that day and any care or treatment provided to that person. The daily report had not been completed each day for an individual receiving residential care. A number of residents had been assessed as requiring to use bed safety rails whilst in bed, however, written assessments and consent in respect of this were not always available. Nutritional risk assessments had not been undertaken, residents were weighed annually unless deemed to be at risk based on the judgements of the nursing staff. Residents have access to dieticians following referral. Residents have access to a wide range of visiting Health and Social Care Professionals, including Social Workers, Medical and Psychiatric Consultants, Opticians, Nurse Specialists, Dentists and Chiropodists. A General Practitioner visits the home on a daily basis if required and there was evidence that the nursing and care staff follow the instructions of these Professionals. Management techniques to aid communication for residents with sensory impairments were being practised. On the residential unit good practice of medicine management was found. Service users were encouraged to self medicate their own medicine and risk Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 Stage 4.doc Version 1.30 Page 11 assessed as able. Regular compliance checks had not been documented. On the nursing unit the Medicine Administration Record (MAR) chart did not accurately reflect practice in all instances. Not all medicines had been recorded as received so audits were difficult to undertake to demonstrate that the medicines had been administered as prescribed and accurately recorded. Medicines had been administered and not recorded. Conversely medicines had not been administered but recorded that they had been. Medicines had not been administered and reasons for non-administration had not been recorded. Doses of medication were not always accurately recorded and thus not administered in accordance with the doctor’s instructions. Prescription Only Medicines had been administered to service users they had not been dispensed for. At the time of the inspection inaccurate entries had been recorded in the Controlled Drug register. Systems installed to check the prescription and the dispensed medication received into the home had not been routinely adhered to in all instances. The home had a comprehensive homely remedy policy, but unfortunately medicines purchased did not reflect this policy. There were no supporting protocols for “when required” medication. The nursing and residential staff had a good relationship with external healthcare professionals and the registered manager was keen to rectify the problems encountered during the inspection. Residents appeared to be very well supported by the home’s staff to meet their personal hygiene needs and to choose to wear clothing appropriate for the time of the year. Residents have the option of making private telephone calls in their bedrooms. Information pertaining to residents’ health care needs was on display in the nurses’ office, which was visible from the main corridor and it is recommended that an alternative location be sought for this with residents’ privacy and dignity in mind. Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 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 The activities on offer meet the needs and expectations of residents. Residents are able to exercise choice over their daily lives and the activities that they choose to participate in which promotes their independence and individuality. Meals provided are wholesome and nutritious and meet any dietary requirements. EVIDENCE: There is a good variety of activities for the residents to participate in should they choose including trips outside of the home, cake decorating, bulb planting, manicures and active games. There was a good supply of large print reading books and a garden fete had been arranged recently and this had been very popular with the residents met during the inspection. Bible readings and hymn singing are available daily and some residents also choose to go outside of the home to practise their faith. Hairdressing is available at the home three times each week and a therapy dog visits each week. Residents can have newspapers delivered to the home. One member of staff said “ The Christadelphian faith makes it very special here”. Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 Stage 4.doc Version 1.30 Page 13 There are good links maintained with the Christadelphian community. One resident said, “We are a very close community here and I have met again many friends from the past since coming to live here”. The home has an open visiting policy and there were a number of visitors at the home during the inspection. The home has a guest room for the family and friends of residents, and this is private and domestic in style. Visitors can choose to have a meal at the home if they wish. Residents can express choice about how they spend their day and can choose to stay in their bedrooms if they prefer. One resident said, “I prefer to stay in my room and can have my meals in my room if I want to, and I have quite a few visitors”. Another resident said “ I can go to bed when I want to”. The menus identified a wide range of nutritious and wholesome meals. The main meal option of the day was cod mornay and an alternative of chicken or omelette was available. All of the residents met were aware that there was always an alternative to the main meal option of the day, however this was not reflected on the daily menus. Portions of pureed diets were served separately in keeping with good practice. One resident said, “If I don’t like the food that is served, there will always be a substitute which I do like”. Another resident said, “The meals are fabulous here and we have a choice of meals”. A number of people who reside in the surrounding mews flats also choose to have meals at the home. Dining tables were laid attractively with appropriate adapted cutlery and plates as required. Staff were assisting residents respectfully during their meals and drinks were served and residents wearing appropriate aprons to protect their clothing as required. It was pleasing to observe that feeding assistants were employed, to ensure that all residents were given the time and opportunity to have their meals at their own pace. Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 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 The complaints procedure is comprehensive and is accessible to the residents and their visitors and there are robust systems in place to protect residents from abuse. EVIDENCE: A comprehensive complaints procedure was on display in the home, in large print and this included the contact details of CSCI. The home had received one complaint since the previous inspection and this had been resolved by the management team in a timely fashion to the satisfaction of the complainant. One resident said “There are several people that work here that I would be happy to talk to or the Manager if I had a problem”. The Registered Manager had received a number of compliment cards praising the service provided. The adult protection and whistle blowing policies incorporated both Birmingham Multi Agency guidelines and the Department of Health’s publication, No Secrets. Staff had received training in the protection of vulnerable adults. All staff working at the home had criminal records clearance and were deemed safe to work with vulnerable people. Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 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, 22, 24, 25 & 26 Olivet provides a homely, comfortable and clean environment to live in, where residents are relaxed and secure. EVIDENCE: Decoration within the internal environment of the home was homely and tasteful in style and generally in a good state of repair. Furniture and fittings were of a high standard and new carpet had been fitted in the lounge and reception area of Garden Wing. The secure and extensive gardens were very attractive and well maintained. There were separate dining and lounge facilities and residents could choose which to use. The home has an adequate number of assisted bathing facilities and the vast majority of bedrooms on Garden Wing are for single occupancy with an en suite facility that included a new walk in shower facility following the Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 Stage 4.doc Version 1.30 Page 16 completion of the recent refurbishment of this area of the home. One resident said, “The best thing is being able to walk into the shower”. The home had an abundance of adjustable beds, pressure relieving and hoisting equipment that were appropriate for the needs of the residents. Wheelchairs are allocated for individual residents’ use following assessment. Each bedroom had a nurse call facility. Bedrooms contained many personal possessions including photos and electrical entertainment equipment. Bedrooms included lockable storage facilities. The temperature of the internal environment of the home was found to be comfortable on the day of the inspection and radiators were of a low surface type. Hot water outlet temperatures are recorded regularly and a Legionella risk assessment had been undertaken recently. The lighting throughout the home was domestic in style. The home was found to be clean and fresh and there were hygienic hand washing facilities throughout. One resident said, “It’s all kept beautifully clean here. I don’t have to ask for my room to be cleaned as it’s always cleaned”. There was a hygienic, effective and well-organised procedure for the laundering of residents’ personal clothing and bedding in place. The home had appropriate facilities for the cleansing of commode pots and for the disposal of clinical waste. Incontinence pads were stored out of their packet on top of toilets and surplus equipment was stored in the downstairs bathroom which may pose a risk of cross infection and an alternative location for the storage of these should be sought. Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 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, 28, 29 & 30 A robust system for staff recruitment is in place. Staff are provided in adequate numbers to meet the needs of the residents and agency staff are not used which ensures continuity of care. Staff undertake a comprehensive induction programme and this ensures that they have a basic knowledge of working within their job roles after commencing employment and all existing staff undertake relevant training to ensure that they work within their job role in a competent manner. EVIDENCE: The staffing rotas identified that the staff were working within approved levels and no staff worked an excessive amount of hours per week. The home has a stable and reliable staff work force. One member of staff said, “There is a very good team spirit here”. The management team provide on call support for the person in charge of the shift. Laundry, housekeeping and kitchen staff provide ancillary support each day. Agency staff are not used. One resident said, “I’ve lived here for over two years and I find all the staff to be very nice”. Another resident said “The carers help me if I want any help, I use my buzzer and the staff answer it”. One visitor said, “The night staff are as excellent as the day staff”. Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 Stage 4.doc Version 1.30 Page 18 A number of staff have achieved the NVQ Level 2 in care award and plans are in place for other staff to work towards this. A number of staff had achieved the NVQ Level 3 in care award and some were NVQ Assessors. Two staff files were sampled and these contained all of the information as required by Regulations. Staff are issued with a statement of terms and conditions of employment and interview notes are kept in keeping with good practice. New staff receive comprehensive induction training including both care and health and safety issues. Staff had received a wide variety of training specific to the job role that they perform including wound care, infection control, dementia care, syringe driver training, palliative care and Parkinson’s Disease. Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 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, 35, 36 & 38 Residents live in a home which is well managed and has a good standard of care, which is regularly monitored for quality. Residents are safeguarded through robust management of personal allowances. The health, safety and welfare of residents is protected through comprehensive staff training and maintenance checks of equipment. EVIDENCE: The Registered Manager is a Registered Nurse with much experience of caring of older people within a management role and holds the Diploma in the Management of Care Services qualification. Residents and staff met during the inspection stated that the management style at the home was open and supportive. Staff meetings are held regularly and residents are able to express their views and put their suggestions forward through the advocacy service provided by Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 Stage 4.doc Version 1.30 Page 20 the Welfare Committee. Due to the large size of the home, methods to improve communication had been implemented for example, the use of communication books. Olivet has a comprehensive quality assurance programme which has achieved a high standard award. This includes the distribution of quality of service satisfaction questionnaires and a report is produced from the findings of these and this is accessible to residents. The Registered Provider undertakes a monthly inspection of Olivet and produces a report of the findings which is sent to CSCI as per regulation 26. Residents and their families were satisfied with the current system for the management of residents’ personal allowances. Separate transaction paper records and money wallets are kept for residents’ personal allowances and a computer record of this is also maintained. Residents and their families can have a computerised statement of their personal allowance account at any time. There were combined receipts issued from the hairdresser and the sweet trolley and these identified the residents that had visited the hairdresser or purchased sweets that day. No signatures were kept of monies in or out of account for residents receiving nursing care, individual receipts were not kept and combined receipts were not numbered for ease of auditing. Although regular audits of the residents’ personal allowance balances were undertaken, a written record of this was not kept. In order to promote their independence, residents receiving residential care are encouraged to manage their own personal allowances with the assistance of the staff and their families and signatures were obtained for all monies in and out of these accounts. A number of staff had received training in staff supervision and appraisal and the formal system for this had been implemented. The accident records were found to be fully detailed, well maintained and this system is audited regularly by senior management to minimise further risks. Health and safety checks in respect of equipment used are undertaken including the fire alarm system fire fighting equipment, portable electrical appliances and hoisting equipment. Staff had received training in health and safety issues including first aid, moving and handling, health and safety and fire safety. In addition, a fire drill had been undertaken recently. Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 Stage 4.doc Version 1.30 Page 21 An Environmental Health inspection had been undertaken recently and there were no requirements made following this as the areas inspected were found to be of a good standard. The door of the COSHH products cupboard was open and a trolley carrying COSHH cleaning products was left unattended. Both issues were brought to the attention of the Registered Manager who addressed these immediately. Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 Stage 4.doc Version 1.30 Page 22 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 x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 4 x 3 3 3 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x 3 3 x 3 Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 Stage 4.doc Version 1.30 Page 23 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 7 Regulation 15(1) (2)(b) Requirement The care planning system must be reviewed to identify individualised care planning and the care plans must be updated each time that there is a change in the care regime to be provided. Nutritional risk assessments must be undertaken to determine which residents are deemed to be at risk of weight loss or gain and these people must be weighed regularly. Residents and/or their representatives must be involved in the agreeing of care plans. (Time scales of 31 October 2004 and 07 May 2005 not met.) Individual care plans must be devised in respect of acute care needs, for example for residents that have an infection or acute medical conditions. (Timescale of 7 April 2004 not met.) All residents care plans and pressure sore risk assessments must be reviewed at least monthly and this must include a Timescale for action 19 November 2005 2. 7 12(1)(a) 14(2)(a) 30 September 2005 3. 7 15(1)(2) 31 October 2005 4. 7 15(1)(2)( b) 15 September 2005 5. 7 15(2)(b) 30 September 2005 Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 Stage 4.doc Version 1.30 Page 24 written review of the care needs. (Timescales of 22 October 2004 and 7 May 2005 not met.) Bed safety rails risk assessments must be undertaken and consent in respect of the use of this type of equipment must be obtained. Policies and procedures must be reviewed and include any new practices implemented in the home and staff must adhere to these. Quantities of all medicines received and balances carried over from previous MAR charts must be recorded. The MAR chart must be referred to during the procedure of administration and staff must sign, or record the reasons for non administration, directly after each transaction. Systems must be implemented and adhered to check the prescription prior to dispensing, and the dispensed medication received into the home. All medicines must be administered to residents they are prescribed to. Adequate supplies must be sought to ensure service users do not run out of prescribed medicines. Staff must accurately record all Controlled Drug transactions in the Controlled Drug register and identify and correct any errors or missing medication and take appropriate action if necessary. 6. 7 13(4)(c ) 15 September 2005 one month and ongoing one day and ongoing 7. 9 13(2) 8. 9 13(2) Schedule 3(3)(i) 9. 9 13(2) one day and ongoing one day and ongoing 10. 9 13(2) 11. 9 13(2) 17(1)(a) one day and ongoing Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 Stage 4.doc Version 1.30 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 10 15 26 Good Practice Recommendations it is recommended that an alternative location for personal information in respect of residents health care needs be sought with residents’ privacy and dignity in mind. It is recommended that the alternative to the main meal option of the day is reflected on the daily menus. It is recommended that either an alternative location is sought for incontinence pads to be stored or pads are stored in a lidded receptacle to prevent the risk of cross infection in bathrooms. It is recommended that an alternative location is sought for the surplus equipment that is stored in the down stairs bathroom to prevent the risk of cross infection. It is recommended that a system for the numbering and subsequent logging of individual receipts for items purchased out of residents personal allowances is introduce. Signatures should be obtained for all monies in and out of the accounts receiving nursing care at the home and there should be written documentation of the regular auditing of this system. It is recommended that the Medicine Administration Record (MAR) charts for the nursing staff are printed every 28 days by the community pharmacist Protocols for “when required” medication should be written and should include reasons for administration, dose, maximum daily dose and dose intervals in addition to the need to record outcome. Examples of medicines that require written protocols are rectal diazepam, benzodiazepines, and antipsychotics. 4. 5. 26 35 6. 7. 9 9 Olivet Christadelphian Care Home E54 S24873 Olivet V231939 190705 Stage 4.doc Version 1.30 Page 26 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. 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