Inspection on 05/07/06 for Rushall Care Centre

This inspection was carried out on 5th July 2006.

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

Rushall Care Centre 19/08/09

Rushall Care Centre 04/11/08

Rushall Care Centre 05/09/07

Rushall Care Centre 18/11/05

Rushall Care Centre 23/08/05

Rushall Care Centre 11/10/04

Rushall Care Centre 27/08/04

Rushall Care Centre 17/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Rushall Care Centre 204 Lichfield Road Rushall Walsall West Midlands WS4 1SA Lead Inspector Mrs Amanda Hennessy Key Unannounced Inspection 5th July 2006 10:30 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 Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 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. Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rushall Care Centre Address 204 Lichfield Road Rushall Walsall West Midlands WS4 1SA 01922 635328 01922 642393 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) the.willows@ashbourne.co.uk Exceler Healthcare Services Limited Ashbourne Homes Limited Maxine Ann Murphy Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 39 Frail elderly over the age of 60 of which 5 may be terminally ill, where the terminal illness commenced prior to admission 18th November 2005 Date of last inspection Brief Description of the Service: Rushall Care Centre is a care home providing nursing and personal care for up to thirty-nine older people. The home was opened in 1990 and is a purpose built, three storey building. The home offers mainly single accommodation and has two communal lounges and a dining room. There is a passenger lift giving access to all three floors. Laundry and catering services are provided within the home. It has recently changed ownership and is now owned by Southern Cross Healthcare. The home is located in Rushall, close to all local amenities and is on a main bus route to Walsall town centre, limited car parking is available. Fees vary between £432.25 and £530 and are dependant on the needs of the service user and the type of room that will be occupied. Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by one inspector. The inspection was carried out between 10.30 and 17.30.The inspection included a tour of the building, talking to service users and staff and a review of records. Thirteen service users completed questionnaires that asked their views on the home identifying life at the home. A review of information supplied by the Manager (pre inspection questionnaire) was also undertaken and expanded upon during the visit. Care records were reviewed as part of the “case tracking” of four service users. The manager is Maxine Murphy. The home has recently changed ownership and is now owned by Southern Cross Healthcare. Fifteen of the previous twenty-eight requirements from the previous inspection have been met. Eight new requirements were made as a result of this inspection. What the service does well: What has improved since the last inspection? The home has changed ownership since the previous inspection. New policies procedures and records have been implemented. A refurbishment plan for the home is being identified. A new washer disinfector, height adjustable beds, door locks and lounge chairs have already purchased. The overall responsibility for medicines has been allocated to a designated member of staff. Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 6 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. Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 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 Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 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): 2,3 The overall outcome for this group of standards is judged to be adequate. Service users have an assessment of their needs giving assurance that the home will be able to meet their needs. Terms and conditions of residency are available but all required information about the home is not always completed. EVIDENCE: The Statement of Purpose and service users guide are reviewed and kept updated providing current and prospective service users with a good source of information about the suitability of the home and the services they offer. Service users are admitted following a comprehensive assessment of their needs undertaken by the Manager. Service users are whenever possible involved in their assessment of needs but this is not recorded. A letter is given prior to admission confirming that assessed needs can be met by the home. Services and their families are also encouraged to visit the home before making the decision to come and stay. Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 9 A contract is provided giving terms and conditions of occupancy at the time of admission. Contracts do not always include the fees payable and the allocated room number as required. There is also a need to ensure that the trial period is extended from four weeks as required by legislation for property disregard. The home does not provide intermediate care and does not intend to do so. Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The overall outcome for this group of standards is judged to be adequate. The home generally meets service users healthcare and personal care needs and respects their privacy and dignity, all medicines are not stored safely. EVIDENCE: Service users have a plan of care that identifies all their needs. Care plans are developed and regularly reviewed. There is a need for the home to ensure that the care plan and its review is undertaken with the service user or their representative and that this is recorded. Further development in care planning must ensure that the care plan is person centred. The home have recently changed all care records to the new company and should be congratulated on this transition. Service users have required risk assessments for the risk of pressure sores, moving and handling, nutrition and falls which are reviewed monthly as required. Service users are weighed monthly and when service users weight is a cause for concern appropriate action is undertaken. One comment from a service user was: “ Most of the time the care is very good and my personal needs considered.” Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 11 Care records and service users identified that they are appropriately referred to and have visits from Health Professionals such as GPs, specialist nurses, dentists, opticians and chiropodists. The administration, safe- keeping and storage of medicines is undertaken by a nursing staff. There is a record of all medicines service users have received. The drugs fridge temperature was considerably warmer than the required safe storage temperature for medicines and required immediate action. The treatment room needs thorough cleaning and additional lockable cupboards for the safe storage of medicines. Over the period of the inspection staff were observed to interact with residents with respect and sensitively to protect service users dignity. Service users spoken to said that the staff were very good, kind and treated them with respect. Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14,15 The overall outcome for this group of standards is judged to be good. The daily life and social activities of the home meet service users needs, capabilities and preferences. Service users enjoy the meals that are served. EVIDENCE: The home provides a good range of social activities both within the home and trips outside the home. Service users all have their social and leisure interests identified and staff try to ensure that activities centre around their interests and capabilities. There are planned activities taking place in each lounge every week day afternoon. The “men’s group” is particularly popular and meets in the dining room two afternoons a week, with activities such as interactive horse racing and grey hound racing, pub games, films and gardening. Recent trips out have included a visit to the theatre to see Beauty and the Beast, a visit to the garden centre and shopping. Visits are also planned to Lichfield Cathedral, Walsall Football Club and a Barge trip. Comments from service users included: “ I do enjoy the activities organised by the home”, “ there is a good variety of activities” another resident said: Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 13 “ I am able to join in with the armchair exercises which I enjoy”. Visitors are welcome at any time and those met said that they felt welcome. Care plans identify residents individual likes and dislikes and choices about their individual routines such as whether they prefer a bath or a shower, getting up and going to bed, these are carried out flexibly to provide for choice. The home has a four-week menu providing a balanced and nutritious food with a choice of meal always provided. Special diets such as pureed, soft and diabetic diets are catered for. Service users spoken to said that they enjoy their meals served and that there is always a suitable choice available: “my diet is always considered and a variety of meals are offered” and “ meals are discussed with us , good quality food is provided”. Staff give residents discreet assistance to feed themselves whenever it is required. Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 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 the following standard(s): 16,18 The overall outcome for this group of standards is judged to be adequate. The home has appropriate policies and procedures to highlight concerns and complaints but needs to ensure that service users are comfortable using these procedures. The Adult Protection policy needs slight amendment to fully safeguard service users. EVIDENCE: The home has an appropriate complaints procedure. The complaints procedure is displayed in the home and is also included in the terms and conditions of residency, the statement of purpose and the service users guide. Despite this comment cards received before the inspection identified that service users were unsure who to speak to if they were not happy and with seven service users saying that they were unsure how to make a complaint. The Manager needs to explore ways to ensure that people know who to state their concerns to, particularly when the Manager is not available. The Commission for Social Care and Inspection have received three complaints about the home since the previous inspection. Two of the three complaints were anonymous. Complainants were concerned about staffing levels particularly at the weekends, the odour and cleanliness of the home and that the lift had broken down and was out of action for some time, all complaints were upheld. The Manager has undertaken appropriate action in relation to these concerns. Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 15 The home has appropriate policies for staff to highlight concerns whilst feeling safe to do so. There is a need to ensure that the Homes Adult Protection policy meets the “No Secrets Legislation”. The Manager has provided additional information for staff about key local contacts if any allegations are made although further information is required. The home has appropriate policies to ensure that staff who are not suitable to work with vulnerable people are not employed by robust recruitment and selection procedures. Staff spoken to have appropriate knowledge of what is abuse and what actions they must take if any allegation of abuse is made to them. Staff receive inhouse training in adult protection procedures. Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21, 24,26 The overall outcome for this group of standards is judged to be poor. Residents live in an environment that is generally clean and homely but would be considerably improved by refurbishment and the addition of additional aids and adaptations for dependent people. EVIDENCE: The home was found to be generally clean, tidy and homely. The home requires refurbishment and a need to review the available facilities for dependent people. The new owners have a refurbishment plan which they have agreed to share with the Commission for Social Care and Inspection. Since the previous inspection new lounge chairs and a sluice disinfector have been purchased, some windows have been replaced and some decoration has been undertaken. It was highlighted again at this inspection as previous inspections that there was a malodour outside the lounge. The Manager has been trying to address the odour problem which was also acknowledged by one comment received by a service user who said: Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 17 “ A lot of effort has recently gone into making sure the home is clean and fresh”. The home has a downstairs lounge and dining room with another lounge upstairs. The downstairs lounge is crowded. Proposals have been made to maximise the dining room as a lounge/dining to address this problem. The lift is unable to accommodate a stretcher should a service user require it, there have been no contingency plans to ensure that should a service user be taken ill they can be taken down stairs both comfortably and safely in the lift as previously required. It has previously been identified that there are occasions that service users have to wait to go to the toilet due to the limited number of larger toilets that can accommodate the hoist. A review of the home and particularly toilets and bathrooms that can accommodate dependent service users who require hoisting is required by a suitably qualified person. The home does have a range of adaptations for dependent people including hoists, assisted baths, grab rails, specialist mattresses, the home does have a number of height adjustable nursing beds but more are required to meet service users needs. The home has a small enclosed garden at the back of the home with a range of garden furniture and a water feature. Several service users were sitting under the gazebo and enjoying being outside on the day of the inspection. It was pleasing to hear that the men’s group had been involved in the planting of the patio pots which service users. Service users’ bedrooms are pleasant with most adorned with photographs and other treasured belonging making them homely and welcoming. Work to replace the front upstairs windows that cannot be opened has commenced. The home suffers from a lack of appropriate storage for wheelchairs, hoists and scales which are stored inappropriately in bathrooms. Locks have been purchased for services users bedrooms and a plan to fit them has been identified. The home’s infection control practices are generally satisfactory. The laundry has appropriate policies and procedures for the management of dirty laundry. A new floor has been fitted as required by infection control guidelines although the broken tiles around the door still need to be replaced. The required additional mechanical sluice has been purchased and is due to be installed shortly. Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The overall outcome for this group of standards is judged to be adequate. The home has sufficient staff to generally meet all service users needs. Recruitment and selection procedures are robust and safeguard the service users. Staff training opportunities are generally good, with a good proportion of qualified care staff enhancing the care that service users receive. New staff do require more comprehensive induction training. EVIDENCE: Staffing levels at the home for 36 service users are: 08.00- 14.00 2 trained nurses and 6 care staff (with one carer starting at 07.00hrs) 14.00-20.00 2 trained nurses and 4 care staff 20.00- 08.00 1 trained nurse and 3 care staff. Additional kitchen, laundry and domestic staff are also available seven days a week. The home also has 2 Activity Organisers with at least one of available every week day afternoon. Service users greatly appreciate the role of the Activity Organisers and commented positively about their work. Staff levels have been increased following previous concerns although some service users highlighted said that they sometimes had to wait to go to the toilet and did not want to ask as they felt a nuisance (see comment within the environment section of this report about the inadequacy of large toilets that can Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 19 accommodate a hoist and subsequently service users having to wait to go to the toilet). The home currently has 10 of its 20 care staff (50 ) with a minimum of National Vocational level 2 qualification (NVQ) or equivalent. The home therefore meets the requirement that they have at least 50 of care staff with NVQ 2. When new staff are employed recruitment and selection procedures are robust to protect the service users. New staff do receive induction training, although required records were not available for all staff. The current induction programme does not meet National Training Organisation standards, however this will be addressed shortly as required induction training is available from Southern Cross the new owner of the home. Staff are supported to undertake further training. Recent training has included fire safety, moving and handling, health and safety and resident welfare. Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36, 38 The overall outcome for this group of standards is judged to be good. The home’s manager is developing and strengthening management arrangements which will increasingly give assurance of the development of the home and the protection of service users. EVIDENCE: The home manager has worked at the home for fifteen years initially as a Staff nurse then as Care manager and for the last two years as Home Manager. There have been many improvements to the home since Mrs Murphy’s appointment as Manager. She has proved that she can manage problematic situations and direct conflicts between service users and their relatives. Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 21 Southern Cross homes have an identified Quality plan for the home. Quality audits are undertaken six monthly with corrective actions identified, with a copy of the audit sent to both the Regional Manager and Regional Director. The home undertake monthly audits of pressure sores, service users weights, accident statistics, vacancies and recruitment, the kitchen and a review of all regulation 37 notifications that have been sent to the Commission for Social Care Inspection (CSCI). Service user surveys are regularly undertaken with identified plans of action identified. Required visits on behalf of the registered company are undertaken. The Manager and registered company proactively identify ways that requirements of Commission for Social Care Inspection will be met. Staff supervision has commenced since the previous inspection, although appropriate records are not always available with staff signing their content. Secure facilities are available for the safe keeping of service users personal money and valuables. Written records are available for all transactions which detail the reason for the withdrawal and two signatures, receipts are available as proof of purchases. Money that was randomly checked in the safe was found to be correct and equal the balance identified. Regular external audits of service users personal money is undertaken. The majority of services users have their finances managed by their families or by the Court of Protection. It was pleasing to hear that one service user manages their own money. Procedures to protect service users include regular checks on the fire alarm, emergency lighting, fire extinguishers, nurse call points and hot water. Records identify that staff regularly attend mandatory training in fire safety, moving and handling, food hygiene, health and safety and resident welfare. Maintenance records and contracts were generally up to date but the required five yearly electrical installation test has not been undertaken. Hazard data on substances that are hazardous to health are available in all areas that the chemicals are being stored or used. Services users safety is compromised by medicines that are left in plastic bags in unlocked rooms. Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 2 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 1 1 x 2 x x x 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 x 3 2 x 2 Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 23 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 OP2 Regulation 5(1)(b) Requirement Terms and conditions of residency must include all requirements of the regulations including the fee and room number allocated. The trial period must be changed in line with the legislation for property disregard. Timescale for action 30/09/06 2 OP3 14 3 OP7 15 4 OP9 13(2) Service users and their 31/08/06 representatives must be involved in the assessment of needs and a record must be available that confirms this. Service users and their 31/08/06 representatives must be involved in the planning and review of their care and a record must be available that confirms this. Medicines waiting for return are 31/08/06 kept in locked cupboards/ containers. Part met- all medicines awaiting return are now kept in the locked treatment room but not within a locked cupboard. Timescale of 19/11/05 not met. The treatment room must be DS0000020795.V303126.R01.S.doc 5 OP9 13(2) 31/10/06 Version 5.2 Page 24 Rushall Care Centre thoroughly cleaning and have additional lockable cupboards for the safe storage of medicines. 6 7 OP9 OP9 13(2) 13(2) Medicines that require storage between 2 and 8oC must be. A date of opening is identified on all short life items. Part met- although the majority of medicines did have a date of opening, two open bottles of calogen had no opening date identified. The Manager and registered company must explore ways to ensure that people know who to state their concerns to and feel comfortable and safe doing so, particularly when the Manager is not available. The protection of vulnerable adults policy must be updated to link and meet the requirements of the local authority protection of vulnerable policy. Part met- the Manager has written information about key local contacts but additional information must be available about actions staff must undertaken. A review of procedures must be undertaken that highlights actions to be taken when a bed bound service user needs to be moved from one floor to another. Not met this requirement should have been addressed by 31/10/05. Alternative door closures to conform to the required standards and linked to the fire alarm system must be fitted. Previous timescale of the DS0000020795.V303126.R01.S.doc 09/07/06 09/07/06 8 OP16 22(2) 31/08/06 9 OP18 13(6) 31/08/06 10 OP19 23(2)(f) 31/08/06 11 OP19 23(4) 31/08/06 Rushall Care Centre Version 5.2 Page 25 31/12/05 partially met. Two door closures have been purchased but more are required to enable residents to have their doors left open and this must not be at the service users expense. 12 OP19 23(2)(d) The stained lounge chairs must be effectively cleaned or replaced. Part met Twelve new chairs have been purchased but more are required as there are still a number of stained chairs, this requirement should have been addressed by the 31/03/06 A review of the home and its suitability to accommodate dependent service users must be undertaken by a suitably qualified person with appropriate and required actions undertaken. The home must have sufficient and appropriate bathrooms to meet service users needs. Doors to service users private accommodation must be fitted with locks to service users capabilities and accessible to staff in an emergency. Service users must be provided with keys unless the risk assessment suggests otherwise. Part met. New locks have been purchased and are waiting to be fitted. This requirement should have been met by the 31/12/05. Adjustable beds must be provided for service users who require assistance with moving and handling. Part met, The home now has twelve height adjustable beds but a further two beds are required to meet the needs of DS0000020795.V303126.R01.S.doc 31/08/06 13 OP22 23(2)(a) 31/08/06 14 15 OP22 OP24 23(2)(a) 12(4), 13(4) 30/09/06 31/08/06 16 OP24 13(5) 31/08/06 Rushall Care Centre Version 5.2 Page 26 service users currently accommodated- this requirement should have been addressed by the 1/6/05. 17 OP25 23(2)(p) All bedrooms must have windows 31/08/06 that can be opened and conform to recognised standards. Part met- some windows have been replaced but a further six require replacement. This requirement should have been addressed by 31/12/05. The home must be kept free of any mal odour. Not met an unpleasant odour remains apparent outside the lounge. This requirement should have been addressed by 28/11/05. The broken tiles in the laundry must be replaced and the laundry floor must be repaired to ensure that it is impermeable. Part met the laundry floor has been repaired but the tiles remain broken round the door. This requirement should have been addressed by 28/02/06 The registered person must ensure that all staff have access to supervision. Partially met- supervision has commenced but records must be confirmed and signed by the member of staff. A copy of the electrical installation test certificate is forwarded to CSCI. Not met this requirement should have been addressed by the 31/12/05 31/07/06 18 OP26 16(2)(k) 19 OP26 13(3) 31/07/06 20. OP36 18(2) 31/07/06 21. OP38 13(4) 31/07/06 Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 27 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 OP8 Good Practice Recommendations Photographs are available of pressure sores to assist staff to evaluate the progress of healing. Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Rushall Care Centre DS0000020795.V303126.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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