Inspection on 09/01/06 for Russell Court

This inspection was carried out on 9th January 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

Russell Court 20/06/07

Russell Court 21/06/06

Russell Court 01/08/05

Russell Court 29/12/04

Russell Court 05/07/04

Russell Court 24/02/04

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Russell Court Overfield Road Russell Hall Estate Dudley West Midlands DY1 2NY Lead Inspector Mrs Cathy Moore Unannounced Inspection 9th January 2006 07:30 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 Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Russell Court Address Overfield Road Russell Hall Estate Dudley West Midlands DY1 2NY 01384 813375 01384 813377 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) N/K Dudley Metropolitan Borough Council Andrew Green Care Home 32 Category(ies) of Dementia - over 65 years of age (9), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (22) Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. All requirements contained within the registration report of 7 January 2003 are met within the timescales contained within the action plan agreed between Dudley Metropolitan Borough Council and the National Care Standards Commission. Day care provision must not encroach on the facilities, staffing and services, provided to residential service users. By the 31 September 2003, all radiators within areas accessed by service users shall not exceed 43 degrees Celsius. In the interim, following risk assessments, strategies are implemented to safeguard service users. Service users to include up to 22 OP, 9 DE(E) and up to 1 MD. When service user category of MD`s placement is terminated new service users must be accommodated within the categories of OP or DE(E) as appropriate. 01/08/05 2. 3. 4. Date of last inspection Brief Description of the Service: Russell Court is a purpose built home, owned and managed by Dudley Local Authority. The home is registered to provide care to a maximum of 32 service users at any one time. Registration categories approved are primarily for older people and nine places for older people who have a diagnosis of dementia. The home offers 32 single occupancy bedrooms, all have en-suite facilities which comprise of a hand wash basin, walk in shower and toilet. The accommodation is divided into four units. Two units are situated on each of the two floors. Each unit provides eight bedrooms and has a comfortable lounge/ dining area and a joining kitchenette. A passenger lift is available to enable access to both floors. Ramped access to and from the home is available. The home has one assisted bath on the ground floor and a number of assisted toilets. Russell Court overall, is maintained in terms of flooring and furniture to a good standard. The home has a generous size garden and a number of car parking spaces. Russell Court offers open visiting times between 7A.M and 11P.M. Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector on one day between 07.30 and 15.40 hours. The inspection was the second of the homes’ two routine inspections for this year. The inspection focused on National Minimum Standards that were not assessed during the last inspection and previous requirements made. Eight residents’, two visitors’ and two staff members were spoken to during the inspection. The kitchen was assessed, as were the laundry and toilets in respect of infection control. Care plans and resident documents were perused as were records pertaining to health care and health and safety. Medication systems were assessed. Meals and menus were examined. Not all standards were assessed during this inspection. For a full overview of service delivery this report should be read together with the previous report dated 1 August 2005. What the service does well: The home is owned and managed by Dudley MBC, it has access to a wide network of guidance and support. All bedrooms are single occupancy with en-suite facilities comprising of a hand washbasin, toilet and walk in shower. The staff are motivated, interested in their work and are keen to provide a good service to the residents’ in their care. The atmosphere of the home is warm, welcoming and friendly. The premises generally, are of a good standard. Positive comments were received from residents’ and relatives which included the following; “ The home is nice and generally clean”. “ The staff are nice”. “ The staff are very friendly”. One resident said,” The home is very nice, we have our own bedrooms and bed linen. The staff are alright on the whole. They try to do anything if you ask. I like to be independent and they let me”. Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The manager has since the last inspection been seconded to another home until the end of March 2006.Although an acting manager is in position this arrangement is not beneficial to the home. In the last years the home has had a permanent substantive manager for less than one year. Satisfaction processes in respect of meals must be continued. One resident said,” The food is good and we have choices”. Another resident however, commented, “ The food is rubbish sometimes”. Staffing levels must be maintained. Whilst it is positive that recruitment has taken place and new staff are to commence employment shortly, the home is operating using a number of agency staff. The afternoon of the 9 January 2006 the care staff team comprised of one new night staff member, two agency staff one of whom has not worked at the home before and a domestic staff member acting in a care role. There has been a domestic and laundry staff shortage having a negative impact on care hours. Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 7 Medication continues to be of a concern. Medication audits have commenced internally these need to be continued. Infection control issues generally and in the laundry need to be tightened. Quality assurance processes must be continued and enhanced. 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. Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 8 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 Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 9 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): Nil No standards in this section were assessed. EVIDENCE: No standards in this section were assessed. Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 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): 8,9. Greater attention must be paid to ensure that the residents’ health care needs are met. Medication processes must be enhanced to promote safety. EVIDENCE: Whilst it was identified that some improvements have been made in terms of health care provision an example being; that residents’ weights are now taken and recorded monthly, further improvement is needed. There was a lack of documentary evidence of health professionals visits in terms of doctors’ visits and the outcomes of such and the frequency of other professional visits examples being the dentist and chiropodist. Concern was raised in that one resident who has a history of bowel disorder and weight loss had been unwell since 3 January 2006 yet the doctor was not called until the 9 January 2006. Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 11 It is positive that evidence was available during this inspection to demonstrate staff medication training and that no staff signatures were lacking on medication records. It is also positive that the homes’ providing pharmacist carries out regular audits of the homes’ medication and medication systems. Improvements are needed to ensure that medication systems in the home are safe. A number of medication records / medication containers still give nonspecific administration instruction an example being ‘ To be taken as directed by doctor’. A number of medication records had been handwritten by staff but not verified by two staff to ensure that information is being transferred from containers correctly. There was a lack of required information on medication records for example any allergies that residents’ may have. Topical preparations are not being signed for on the medication or other records. Concern was raised in that one resident who had been unwell had been given Fortisips – a prescribed food supplement, yet she had not been prescribed these by her doctor. Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 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): 14,15 Residents’ are helped to exercise choice and control over their lives. Further developments are needed in terms of meal provision and the documentation of food consumption records. EVIDENCE: Residents’ are encouraged to and do bring into the home personal possessions of their choosing ranging from small pieces of furniture to pictures and ornaments. It is positive that these items are recorded on personal inventories. Resident information is submitted to electoral services to enable them to vote. It is positive that information pertaining to external advocacy services is displayed within the home. The kitchen was assessed, food stocks were plentiful. There was a variety of fresh foods, vegetables, salad and fruit, cheese and meat. Menus are interesting and varied but lack supper options. Food consumption records require greater diligence when completing an example being; the lack of dates. Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 13 Residents’ spoken to had mixed views about the food one said;” The food is nice and we are given choices” another said; “ Sometimes the food is o.k. other times it is rubbish”. Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 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): 18 Generally residents’ are protected from abuse. EVIDENCE: Dudley MBC’s adult protection procedures titled ‘ Safeguard and Protect’ were available within the home. It is positive that 18 staff to date have received abuse awareness training. At least 5 staff however, have not received this training. The department has its own in-house policies and procedures aimed to protect vulnerable adults. These require a review. Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 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 the following standard(s): 26. Further developments are needed to ensure that the home is at all times clean and hygienic. EVIDENCE: The home has encountered shortages in respect of domestic and laundry domestic staff. Domestic and laundry posts are not always covered when the substantive staff member is off. The impact of this is communal toilets, which are not adequately clean and laundry cleaning schedules not being consistently adhered to. Care staff attend to the most urgent cleaning/laundry tasks which does at times deplete care delivery time. It was noted that there was a lack of ‘hand wash’ signs in bathrooms and toilets. The mop in the laundry was soaking in a cold liquid. Generally however, the home was tidy and visually clean. No offensive odours were detected . One resident commented,” The home is generally clean”. A visitor said,” The home is all nice and clean”. Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 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 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): 27,30. Residents’ needs are not always being met by the numbers and skill mix of staff. Generally, staff are trained and competent to do their jobs. EVIDENCE: The home has encountered staffing shortages for some time due to vacant posts and sickness. Vacant posts/sickness are being covered by internal staff as extra shifts or agency staff. At times the majority of staff on some shifts are agency staff giving concern about consistency of care. It is positive however, that vacant posts have been appointed into. The home is awaiting the required staff checks before employment can commence. The acting manager has revised staffing rotas. The new rotas came into being on 9 January 2006. They are aimed to make better use of the staff hours allocated to include domestic and care staff. The home has a training matrix where staff training is detailed. Evidence was available to demonstrate that new staff attend induction and foundation training to the prescribed specifications. No new staff have commenced employment since the last inspection. Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,37,38. The registered manager is at present on secondment at another home. Record keeping requires a review to ensure that all complies with access to records and Data Protection guidance. Generally health and safety is adequately observed within the home. EVIDENCE: The registered manager at the present time is on secondment to another home. The home over the previous three years or so, has only had a registered manager in post for 10 months. Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 18 It was noted that staff handover documentation includes personal, confidential information about residents’ which should only be recorded on their personal files. For example for one resident a message in a communal handover book described problems with his catheter. Health and safety and maintenance records were randomly assessed. Hoisting equipment has been serviced within the last 6 months; the fire alarm system was serviced in April 05; the fire fighting equipment serviced in June 05. Previous problems with the water system have mostly been resolved although problems in water temperature fluctuation does occur at times. Confirmation that work has been completed in respect of the homes water testing and fixed electrical wiring was not available for inspection. The kitchen was briefly checked generally it was well maintained and in good working order. More fly screens are required for the windows. The staff must ensure that they date label all short life products for example sauces, on opening. Generally staff mandatory training is up to date however, one shortfall identified is first aid training in respect of 5 staff. Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 x x x x x x x 2 STAFFING Standard No Score 27 2 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x x x 2 3 Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5(1)(b) (c ) Requirement The registered person and manager must ensure that the contract/ terms and conditions document is updated and revised in accordance with current guidance and practice. Terms and conditions/ contracts have not been updated. The registered person must ensure that each service users care plan is reviewed monthly or when changes occur. Timescales of 10.1.05 and 15/8/05 not fully met. Timescale for action 01/03/06 2 OP7 15(1)(b) 25/01/06 Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 21 3 OP7 15(1) The registered person and manager must; Review and expand service user plans to include long and short term goals, all aspects of care (social needs, diabetic care, oral hygiene, personal care, pressure area care, incontinence etc). Timescales of 10.1.05 and 01.09.05 not fully met. This also to include any risks or concerns due to poor physical health, behaviour etc. The registered person and manager must ensure that care plans detail full instructions to staff detailing what must be done, how, when, by whom and how often. The registered person must ensure and encourage all residents to have regular dental checks for diagnostic and preventative purposes. Timescale of 01/09/05 not met. There remains a lack of evidence/ recording of healthcare visits. The registered person and manager must ensure that the rating score is detailed on each dependency assessment tool document to inform staff what dependency level each resident has. Timescale of 10.08.05 not fully met. 25/01/06 4 OP7 15(1) 15/08/05 5 OP8 13(1)(b) 01/02/06 6 OP8 12(1)(a) 13(2)( C) 01/02/06 Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 22 7 OP8 12(1)(a) The registered person and manager must ensure that records are maintained to indicate the personal care delivered to each service user on a daily basis. Timescales of 29.12.05 and 01/08/05 not fully met. The registered person and manager must ensure that the preferred method of personal care (bath or shower) must be determined in respect of each resident, be reflected in there care plan and honoured wherever possible. The registered person and manager must ensure that all staff receive training in diabetes awareness. Timescales of 20.1.05 and 01.09.05 not met. The registered person and manager must ensure that appropriate medical attention be secured immediately if any residents’ health or condition deteriorates / or becomes a cause of concern. An Immediate requirement followed by a serious concern letter were issued/ sent to the registered person to this effect by the CSCI. 01/02/06 8 OP8 13(2)(a) 01/02/06 9 OP8 12(1)(a) 18(1)(a) 01/02/06 10 OP8 12(1)(a) 12(1)(b) 09/01/06 Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 23 11 OP9 13(2) The registered person and manager must purchase/ obtain an approved tool for cutting tablets where tablets have been prescribed to give half. Timescale of 10/08/05 not met. 01/02/06 12 OP9 13(2) The registered person and manager must confirm with each residents doctor where applicable the prescribed topical preparations required. Those that are required must be: Detailed at all times on the residents medication record and be signed for after application. Be suitably stored at all times either by the resident if they have been assessed as safe to self medicate or by the staff. Timescale of 10/08/05 not fully met. The registered person and manager must request that the homes pharmacy provider gives a view on the suitability of the cupboards used to store medication in the home . They must be asked to record the outcome/ their view on the next medication audit report. A copy of which must be provided to the CSCI office. Timescale of 09.05 not fully met. There was no documentary evidence that this requirement had been addressed. 01/02/06 13 OP9 13(2) 01/03/06 Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 24 14 OP9 13(2) The registered person and manager must check with a reliable source (doctor) the medication , dosage, frequency of administration of prescribed medication for each new service user admitted to the home. This must then be included on the service users care plan. Timescales of 25.1.05 and 15.08.05 not fully met. The registered person and manager must ensure that a section is available in each residents care plan in respect of medications. This must be maintained and updated when there are any changes to medication. Timescales of 25.1.05 and 10.08.05 not met. The registered person and manager must request that doctors prescribe using precise instructions rather than As directed. Where As directed is presently detailed on medication records/ medication boxes these must be changed with the monthly ordering by consultation with the doctor and / or pharmacy provider. Timescale of 01/09/05 not fully met. The registered person and manager must ensure that a section is specifically dedicated in the medication cupboard to store topical preparations. These must be stored away from oral medications. Timescale of 20.08.05 not met. 25/01/06 15 OP9 13(2) 01/02/06 16 OP9 13(2) 01/02/06 17 OP9 13(2) 01/02/06 Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 25 18 OP9 13(2) The registered person and manager must ensure that ‘Fortisips’ or any other preparation must not be given to any resident unless they have been prescribed for them. An Immediate requirement followed by a serious concern letter were issued/ sent to the registered person to this effect by the CSCI. 09/01/05 19 OP9 13(2) The registered person and manager must ensure that prescribed preparations must only be given to the person they have been prescribed for. An Immediate requirement followed by a serious concern letter were issued/ sent to the registered person to this effect by the CSCI. 09/01/06 20 OP9 13(2) The registered person and manager must ensure; That where medication records are handwritten two staff sign to confirm that the information transferred from medication containers to the medication records is correct. That all medication records contain the correct information this to include for example allergies, the doctors name, residents’ date of birth. 25/01/06 Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 26 21 OP9 13(2) 22 OP9 13(2) 23 OP9 13(2) 24 OP10 12(4)(a) (b) The registered person and manager must ensure that all prescribed preparations for example food supplements and creams are signed for when given. The registered person and manager must consult with (FN) doctor to determine if her prescribed Diclofenic Sodium that has not been administered per prescribing instructions is still required. The registered person and manager must ensure that where a choice of dosage is available for example, one tablet or two the number actually given is recorded on the medication record. The registered person and manager must ensure that the preferred name of each resident is determined, recorded and used. Timescale of 15.08.05 not fully met. 09/01/06 20/01/06 25/01/06 09/02/06 25 OP10 12(4)(a) (b) The registered person and manager must determine from each resident their preferred gender of staff in respect of personal care delivery. This must be recorded on their personal file and adhered to. Timescale of 15.08.05 not fully met. 01/02/06 Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 27 26 OP10 12(2) The registered person and manager must ensure that preferred daily routines (rising and retiring times, meal times, bathing/ showering times etc) are determined in respect of each resident be reflected in their care plan and honoured whenever possible. Timescale of 01/09/05 not fully met. The registered person and manager must ensure that individual activity/ stimulation programmes are produced and provided to residents who are frail, unable or who would prefer this one to one attention. Timescale of 01/09/05 not fully met. The registered person must ensure that the activity participation tick chart in respect of each resident is diligently and consistently completed. Timescale of 01/08/05 not met. 01/02/06 27 OP12 12(1b) (4b) 16(2m(n) 01/02/06 28 OP12 16(2)(m) (n) 01/02/06 Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 28 29 OP15 12(1)(a) 17(2) The registered person and manager must ensure that all residents special dietary needs are identified and that a plan is produced. (low fat diets, low cholesterol diets, diabetics, diets for residents with poor appetites, weight loss or who are at risk nutritionally or otherwise). Timescale of 10/08/05 not fully met. The registered person and manager must ensure that each residents’ daily food consumption charts are dated. The registered person and manager must ensure that supper is added to the home’s menus. The registered person and manager must ensure; That all staff receive abuse awareness training ( who have not already). That the homes policies and procedures aimed to protect vulnerable people are reviewed. The registered person and manager must ensure that the homes maintenance programme continues to: Ensure that the six highlighted bedrooms are redecorated. Replacement of furniture. 01/02/06 30 OP15 17(2) Sched 413 17(2) Sched 413 13(6) 25/01/06 31 OP15 01/02/06 32 OP18 01/03/06 33 OP19 23(2)(b)2 3(2)(d) 01/04/06 Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 29 34 OP21 23(2)(j) The registered person and manager must ensure that an assisted bathing facility is provided on the first floor. Timescale of 01.10.05 not met. 01/03/06 35 OP24 12(4)(a) 16(2)(l) The registered person and manager must ensure: That all residents who have been assessed as safe to, and want to, are provided with a key to their bedroom door. That all residents are provided with a key to their lockable cabinet and that these are in good working order. Timescale of 01.09.05 not fully met. The registered person and manager must; Carry out regular audits of the toilets and bathrooms in relation to cleanliness. Ensure that all plastic trims and flooring in bathrooms and toilets are intact. 01/02/06 36 OP26 13(3) 01/02/06 37 OP26 13(3) The registered person and manager must ensure that hand wash signs are available in all high risk areas examples being; toilets, bathrooms and the laundry. 01/02/06 Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 30 38 OP26 13(3) The registered person and manager must ensure that; All mops used within the home are cleaned at high temperatures daily and are hung to dry when not in use. Personal care items examples being shower cream and bar soap are not left in communal bathrooms. 25/01/06 39 OP33 24(1) The registered person and manager must continue with the progress made in respect of quality monitoring systems. To be in full operation by timescale set. 01/04/06 40 OP36 18(2) The registered person and manager must continue with progress made in respect of the supervision of staff. All staff, including night staff, must receive 6 supervisions in any 12 month period . Timescale of 01/09/05 not fully met. The registered person and manager must ensure that personal information about residents’ is not written in handover or communication books. 01/03/06 41 OP37 12(4)(a) 17(2) 25/01/06 Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 31 42 OP38 13(2)(c) 18(1)(a) The registered person and manager must continue to ensure staff receive all mandatory training required. This mainly relates to four staff who have not received first aid training. 01/02/06 43 OP38 13(3) The registered person and manager must ensure that a copy of the homes water test results ( arranged for 2.8.05 ) are forwarded to the CSCI 01/02/06 44 OP38 13(4)(a) ( c) 45 OP38 13(3) 16(2)(j) 13(3) 16(2)(j) 46 OP38 The registered person and manager must provide the CSCI with a timescale detailing when the work required on the five year fixed electrical wiring report will be attended to. Or evidence that the work has been carried out. The registered person and manager must ensure that kitchen windows are fitted with fly screens as per EHO report. The registered person and manager must ensure that all ‘short life’ items for example preserves and sauces are date labelled when opened. 01/02/06 01/04/06 25/01/06 Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 32 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. Refer to Standard OP8 OP33 Good Practice Recommendations The registered person and manger should retain upon each service users file a copy of their continence assessment. The registered person and manager should consider how to obtain feedback from stakeholders in the community. Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 33 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 Russell Court DS0000041944.V274835.R01.S.doc Version 5.1 Page 34 - 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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