Inspection on 18/09/07 for Selly Park Care Centre

This inspection was carried out on 18th September 2007.

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

Selly Park Care Centre 29/09/09

Selly Park Care Centre 04/10/06

Selly Park Care Centre 24/04/06

Selly Park Care Centre 27/10/05

Selly Park Care Centre 31/05/05

Selly Park Care Centre 13/10/04

Selly Park Care Centre 16/04/04

Selly Park Care Centre 16/01/04

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 Selly Park Care Centre 95a Oakfield Road Selly Park Birmingham West Midlands B29 7HW Lead Inspector Kath Strong Unannounced Inspection 18th September 2007 09:45 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 Selly Park Care Centre DS0000024886.V347322.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. Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Selly Park Care Centre Address 95a Oakfield Road Selly Park Birmingham West Midlands B29 7HW 0121 471 4244 0121 471 1107 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) Exceler Healthcare Services Limited Linda Norton Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 50 General nursing care. Males and females over the age of 65 years Date of last inspection 4th October 2006 Brief Description of the Service: Selly Park Care Centre is a converted Victorian building that has been extended to offer 24 hour care for up to 50 older people with nursing needs. The home is built around two internal well maintained and attractive courtyard gardens that allow secure access for residents, visitors and staff. There is a car park to the side of the home, which can accommodate 11 vehicles. The building is located in a pleasant residential area in Selly Park and is within easy access to main bus services from the city centre. The home offers mainly single rooms, eight rooms are of double occupancy rooms and there are three en suite rooms available. A few bedrooms are situated on the ground, the majority are located on the first floor and there are two passenger lifts servicing both wings of the Home. The home has an adequate supply of specialist equipment and lifting aids to promote health and safe mobilisation of residents. There are three lounges and two dining areas available and a further small lounge is used for social events and activity sessions. There are four assisted bathrooms, two assisted shower rooms and a good supply of toilets strategically located throughout the home for ease of access. The staff training room is situated on the first floor. There is a range of specialist equipment for use to prevent pressure ulcers occurring for those people who are assessed as being at risk. Various aids are used by staff to ensure that safe transfers are carried out on people who have restricted mobility. The call system extends to all rooms to enable people to summon assistance. There is a small reception area, which includes display information, notice boards containing information about current events, service information and a copy of the latest CSCI report is also easily accessible. The current charges are included in the contract of terms and conditions of residency. A copy of this is issued to all people when they move into the home. The manager advised during the inspection that the fee rate should not Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 5 be included within this report. Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The home did not know that the fieldwork visit would be carried out; this is to enable the inspector to obtain a true picture of the standards of the services provided. On the day of the visit, the home had 42 people living at the home. The administrator supplied the manager provided assistance and some information. At the conclusion feedback was given to the manager. No Immediate Requirements were made. Information was gathered from speaking with people who reside at the home, relatives and staff. Care, health and safety and the arrangements for medications were inspected. Staff personnel files were checked and staff were observed whilst performing their duties. A partial tour of the premises was carried out. Two of the five care plans reviewed were case tracked. This involves obtaining information about individuals’ experiences of living at the home. This is done by meeting with or observing people, discussing their care needs with staff, looking at care plans and focussing on outcomes. Tracking peoples care needs and how the care is delivered helps us to understand the experiences of those people. Prior to the visit the home had completed the annual quality assurance assessment and sent it to CSCI. The information within the document advised of what the home does well, improvements made during the last 12 months and what the home would like to further improve. This provided details that contribute to the inspection process and highlights areas that may be explored during the fieldwork visit. A number of people who live at the home were requested by the inspector to complete a questionnaire. These give personal opinions about the services provided and are included in this report. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is based upon the outcomes for people who live in the home and their views about the services provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and aspects of service provision that need further development. What the service does well: People are provided with a range of information about the home so that they can make an informed choice about whether to live there. Access to a range of external healthcare professionals is good and staff actively request these services to ensure that all healthcare needs are met. Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 7 People are encouraged to participate in the activities programme and are able to voice their opinions and influence the contents of the programme. This indicates that people can control the recreations they participate in. There is a friendly atmosphere and people are supported in personalising their own bedroom to promote their personal space in a way that pleases them. The manager has an ‘open door’ culture so that anyone can approach her for information or assistance. She also operates a weekly evening surgery to assist visitors in having one to one discussions about their relative. Staffing levels are consistent to ensure that all of peoples needs can be met appropriately and in a timely fashion. Questionnaires returned from people who live in the home and their relatives were al positive and some contained complimentary feedback about the staff and the services provided. During the visit some of the comment received were, “I like it here, I’m happy with everything”. What has improved since the last inspection? Most of the six requirements made at the last inspection had been met. This indicates that the inspections are viewed positively and that staff are striving to make improvements for the benefit of those who live there. Care plans have been adapted to care for Muslim people that takes into account their personal needs during dying and death. Signage has also been introduced to ensure that staff act accordingly during this period of peoples lives. The home has introduced a weekly newsletter to keep people informed about ‘what is going on’ around the home. Work has been carried out in respect of care planning to promote peoples health and well being. The manager has attended a trainer’s course in safe moving and handling and is able to train staff and observe staff practices in this aspect of care to ensure that staff are using safe practices. Following requests made by people who live in the home the main meal of the day is now served during the early evening. Feedback obtained during the visit indicated that people were happy with the change. The home has improved the access of the range religious clericals who visit the home. This will improve peoples ability to meet their spiritual needs. Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 8 Carpets have been replaced in some areas with wood effect flooring to address the mal odour that was previously prevalent. New table linen and glasses have been purchased to enhance people’s enjoyment during mealtimes. Bedrooms are redecorated on a rolling basis. A maintenance schedule was on display in the manager’s offices. This ensures that people are provided with fresh and pleasant personal space. 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. The summary of this inspection report can be made available in other formats on request. Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 9 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 Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ample information is available for prospective people and their representatives to assist them in making an informed decision about living at the home. Comprehensive pre-admission assessments are carried out and other information gathered so that people know that the home can meet their needs by the time they move in. EVIDENCE: Copies of the statement of purpose and service user guide are readily available for people to read. Other information and a copy of the latest inspection report are also accessible at the reception area. A copy of the service user guide is kept in each bedroom to give people instant access to information about the care they can expect to receive. Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 11 Comprehensive pre-admission assessments are carried out and other relevant information is gathered in order for the home to obtain a full picture of peoples needs and to ensure that the home is able to meet those needs at the time of admission. The pre-admission assessments of two recent admissions were reviewed and it was noted that there was adequate information to establish their needs. The home does not provide intermediate care but may offer respite care following a full assessment. Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Peoples healthcare needs are well met and this is in the main evidenced in peoples care plans. Staff practices in respect of medications are good; this means that people receive their prescribed medications to promote their health. Observations of staff indicted that peoples privacy and dignity are being maintained. EVIDENCE: Each person has a written care plan. This contains details of assessments carried out and an individualised plan of care and staff guidance about how and when care needs to be delivered. Five files were seen, two of which formed part of the case tracking process. Most care plans provided detailed information for staff to follow to ensure that needs could be met, some further work is required to ensure consistency across all files. In one file the numbering system for the care plans was found to be incorrect. Another file did not have care plans developed for type two Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 13 diabetes or chronic arthritis and arthritis in another. A file states occasional urinary incontinence but later states frequent in the urinary assessment section of the file. These shortfalls and inconsistencies need to be addressed and other files checked. One file contained lots of good information the persons life history and background, however some inaccuracies were noted. Two people presuming at different times had documented the details but neither had dated or signed the form. One entry stated that the person has one daughter but the other entry states that the individual has three daughters. Such recordings may lead to embarrassing situations for both parties and therefore needs to be corrected. There was evidence of care plans being developed for possible short term illnesses and this is viewed as being good practice. There was plenty of evidence to support that external professionals are asked to visit the home and to supply their expertise and guidelines for staff to follow. Such practices suggest that staff promote peoples health and well being. Risk assessments were seen regarding safety within the home and where people go out unaccompanied further risk assessments had been collated. This ensures that identified risks are accompanied by action plans to reduce the risks as far as practically possible. Positive comments were made by people living in the home, “I’m happy here and would not like to go anywhere else, staff are kind, I’m happy with everything”. The management of medications was found to be good, meaning that people receive their prescribed medications in a safe manner. Four of the five care plans seen were audited in respect of medications. The manager and deputy manager carry out regular audits before and after administration of medications so that any errors identified can be dealt with quickly and effectively. The home has developed a system for recording details about how individuals wish to have their medications such as, needs to be offered one tablet at a time and the type of drink required. This is excellent work that the home should be commended for. Staff were observed using the preferred term of address towards people. Personal care was delivered in the privacy of a bathroom or their bedroom to preserve their privacy and dignity. Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to influence what activities they participate in, this promotes their independence and individuality. A varied and wholesome diet, which meets any specific dietary, cultural needs and preferences are provided. EVIDENCE: The home has a dedicated activities organiser who reviews the activities programme each week. The manager advised that late changes can be made to the programme to accommodate peoples preferences. To assist people in their understanding of the activity to be provided laminated cards have been produced that provide pictorial descriptions. This is viewed as being good practice and a useful communication tool. The activities organiser generally works weekdays but is also willing to cover weekends when specific activities have been organised. There was evidence of ample activities such as board games, weekly coffee mornings, one to ones in peoples own bedroom, bingo, sing a longs and a large range of videos. External people come into the home and provide entertainment on a regular basis. Some people are of ethnic minorities and staff have ensured that they receive entertainment to suit their preferences. Religious people of differing denominations regularly visit the Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 15 home and arrangements have also been made to meet the spiritual needs of people of ethnic minorities. Recordings are made about each person who has participated in an activity. Outings are organised and volunteers are encouraged to assist with them to promote peoples enjoyment of the day. The recently introduced newsletter appeared to be popular and the manager advised that any person living at the home may act as a reporter. The manager is also organising a knock out quiz with a sister home, a trophy has been ordered to heighten the entertainment. Regular residents and relatives meetings are held and the minutes indicate that opinions are taken into account and where possible suggestions are implemented. The main meal is now served during the evening; this was introduced at people requests and is being monitored for its success. Visitors are welcome at any time and they are encouraged to participate with internal activities and assist with outings. Comments were received “Went to the pub for lunch, it was very nice, I’ve got a low greenhouse to grow seeds to make up the hanging baskets and containers”. Lunch was served in light and pleasant room, which is integral with the main lounge. Tablecloths, place mats, napkins and flower arrangements were on the dining tables. This is to ensure that people have their meals in a pleasing environment. Appropriate assistance was given and staff provided gentle encouragement and offered people choices. The meal was nicely served from a hot trolley in each of the dining areas. Halal meals were also served. The four week rolling menu was noted to offer a well balanced and nutritious diet. Attention to detail is required regarding the habit of staff replacing unused cutlery in the storage tray that people had been fingering during the meal time. The evening meal was also observed being served and staff appeared to give appropriate assistance. Feedback from people included, “It’s lovely, lovely food, the food is OK”. Positive comments were received about the recent change regarding the main meal being served during the evening. Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are confident that their opinions are listened to and if a complaint is made that it will be dealt with effectively. In practice people are protected from risks of abuse but this is not fully evidenced in the written staff guidance. EVIDENCE: The comprehensive complaints procedure is readily available to enable people who live at the home and their representatives if they need to make a complaint. Since the last inspection the home had received one complaint regarding hygiene. Senior staff responded positively to the concern. CSCI had also received a complaint about the management of the home. An investigation was carried out by the responsible individual and it was determined that the Regulations had not been breached but action was put in places to ensure that communications remained good. The home was noted to have responded to the requirement made at the last inspection about the written adult protection policy needing amendments. All staff have received training in adult protection to provide them with the knowledge and skills to respond appropriately where abuse is suspected or confirmed. Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A homely, clean and fresh environment is provided and people appeared to be safe and secure. EVIDENCE: The interior of the home provides a warm and pleasing environment with a number of lounges and dining areas for people to choose from. The main lounge includes an integral dining room; there are three further interlinked lounges and a separate attractive dining room. The home was found to be on the whole, clean and fresh. On entry to the home the reception area provides a comprehensive amount of written information for people to refer to at any time. The main lounge has an integral dining room and a kitchenette off where people can help themselves to refreshments. People and their visitors can also access the activities room located on the first floor for use as a quiet Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 18 room or peoples own bedrooms. The dining rooms looked welcoming with the new tablecloths, napkins and tablemats. The corridors are narrow and can be restrictive for wheelchair users. There is a written rolling programme for redecorating peoples bedrooms. This provides them with a pleasing personal space. The flooring in some communal rooms has been replaced with non-porous flooring that is easy to keep clean. There is a dedicated hairdressing room to promote peoples experiences when being attended by a hairdresser. There are two attractive gardens where people can sit with visitors during warm weather. One bathroom was spot checked on the first floor and it was noted to have an extractor fan that was clogged with dirt. This may account for the slightly musty odour in the room. This should be dealt with to ensure that people bathe in a pleasant and odour free environment. The bedrooms of the people whose care plans were seen were visited. They were noted to be personalised to the extent preferred by the occupant. Bedroom door locks have been fitted so that people may lock their rooms to ensure their desired privacy is maintained. One shared room seen although clean in appearance had a strong mal odour that needs eradicating. A further concern that was brought to the attention of the manager was the loud creaking floorboards that may result in disturbed sleep during checks carried out by staff. This shortfall requires some attention. Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels are maintained to meet the needs of people living in the home. Robust practices in respect of staff recruitment protects people fro risks of harm. The workforce is supplied with appropriate training to enable them to meet the specialist needs of people. EVIDENCE: The arrangements for staffing levels were reviewed. There appears to be adequate numbers of trained and carers to carry out the personal and healthcare needs of the people living in the home. Care staff are complimented by a full range of ancillary staff to enable them to carry out their dedicated roles. Review of a number of staff personnel files suggested that all relevant checks are carried out before the applicant is permitted to commence employment. This practice helps in protecting people who live in the home from risks of harm. Newly appointed carers are expected to undertake an induction that reflects the contents of the Skills for Care programme to provide them with the basic skills of working within the care sector. Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 20 Care staff have not yet met the required 50 target of staff who have successfully completed training in NVQ level 2. However 68 of staff are currently undertaking the course. Staff have received mandatory training in Health and Safety, Moving and Handling and Fire Safety. The manager who is now the trainer in Moving and Handling; has arranged for refresher courses to be completed by staff. Other training that staff have undertaken include, Medications, Infection Control and Dementia Care. This provides staff with the knowledge and skills to carry out their roles effectively. Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the knowledge and skills to run the home and has a clear vision for the future development of the home. The quality assurance programme ensures there are consistently improving standards for the benefit of those who live in the home. The health and safety arrangements serve to protect people for risks of injuries. EVIDENCE: The registered manager possesses lots of experience in managing in the healthcare sector. She has recently completed the trainer’s course in Moving and Handling. This knowledge enables her to observe staff practices on a day to day basis as well as provide the required training. She is supported by the clinical manager who oversees staff practices by working alongside them. She Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 22 also assists with the management of the home. During the fieldwork visit it was evident that management adopt an ‘open door’ approach to all people who may need to discuss issues or require guidance. As part of the overall organisation the home is required to carry out a vast range of audits. The manager also carries out audits that reflect the seven sections of standards, which this inspection is based upon. Questionnaires are sent to residents and their families three times a year. The results are analysed and where any shortfalls are found an action plan with a timescale for resolution is developed. The responsible individual carries out unannounced monthly checks and gives the manager a written report. These practices indicated that there are continual improvements being made for the benefit of people living in the home. The process for the safekeeping and management of financial transactions of peoples personal monies appeared to be robust. This prevents the risk of financial abuse. The accident records are good and CSCI are informed of any concerns that affect the health and welfare of people living in the home. Relevant checks are carried out and servicing of equipment was found to be taking place. The maintenance operative carried out regular testing of hot water outlets that people come into contact with to prevent scolds from occurring. Fire alarms and emergency lighting are tested and the results recorded to check their integrity in the event of an emergency situation. Staff receive regular fire drills and the names of those who have attended are recorded to ensure that all are captured over a twelve month period. The arrangements in place appear to protect people living in the home and others from risks of injuries. Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 23 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 3 X 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 17 X 18 3 3 3 3 X X 3 X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15(1)(2) (a-d) Requirement Care plans must provide comprehensive and consistent information and reflect the actual care afforded. Documentation regarding assessments need to include the correct information throughout the files. Care plans must be developed for all identified illnesses. These are required to ensure that all care needs have been identified, assessed and care planned to meet peoples healthcare needs. Timescale for action 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 25 No. 1. 2. 3. 4. 5. Refer to Standard OP20 OP20 OP21 OP24 OP28 Good Practice Recommendations Consideration should be given to the integrity and acceptance of floorboards on the first floor that are adjacent to peoples bedrooms. Consideration should be given to repairing or replacing the floor lining material of the shaft lift in order to prevent accidents from occurring. It is recommended that the extractor fan of the first floor bathroom be thoroughly cleaned and the odour in the room reviewed. Work needs to be carried out to eradicate the mal odour that was prevalent in bedroom 24 to ensure a more pleasing personal space is provided for the occupants. The already commenced work needs to be completed for at least 50 the care staff to achieve the NVQ Level 2 qualification. Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Selly Park Care Centre DS0000024886.V347322.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!