Inspection on 27/10/05 for Selly Park Care Centre

This inspection was carried out on 27th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Selly Park Care Centre 29/09/09

Selly Park Care Centre 18/09/07

Selly Park Care Centre 04/10/06

Selly Park Care Centre 24/04/06

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 Amanda Lyndon Unannounced Inspection 27th October 2005 10:10 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.V257835.R01.S.doc Version 5.0 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.V257835.R01.S.doc Version 5.0 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) Ashbourne Healthcare Services Limited Vacant 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.V257835.R01.S.doc Version 5.0 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 31 May 2005 Brief Description of the Service: Selly Park Care Centre is a converted Victorian building that has been extended to offer 24 hour care for 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. The Home 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 with a small number of double occupancy rooms and there are also en suite rooms available. The bedrooms are situated on both the ground and first floors and there are two passenger lifts servicing both wings of the Home. There are three lounges and two dining areas available and a further small lounge is used for social events and activity sessions. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken over two visits by three Inspectors, including the Pharmacist Inspector when there were forty seven residents living at the Home. Information was gathered by speaking with residents, visitors and staff, examining care, medication and health and safety records and observing the staff perform their duties. A full tour of the Home was undertaken. This is the second inspection of this service in the 2005/2006 inspection year and linked to the Commission’s focus on outcomes for residents and proportionate inspection, we would recommend that you read this report in conjunction with the last inspection report of this service on 31 May 2005. What the service does well: Despite areas of concern in respect of the care provided at the Home as identified in this report, the majority of residents met during the inspection expressed their satisfaction about the service provided at Selly Park Care Centre. One resident said “ I enjoy living here, I’m looked after well”. Another resident said “ Some of the nurses are very good indeed, they do the best they can with what they have got”. Medication is administered to a high standard and this ensures the safety of residents in this area and this is to be commended. Residents receive a choice of wholesome and well balanced meals. One resident said “ The Chef cooked a curry and it was smashing”. All complaints made about the service provided at the Home are investigated by the management team in an appropriate and timely manner. Adequate staffing levels are maintained to meet the needs of residents and the Home do not use agency staff which promotes continuity of care. The health, safety and welfare of residents are protected through staff training. Group meetings are arranged in order for those living at the Home to put forward their comments and suggestions about the service provided at Selly Park Care Centre. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 Page 6 There is a robust system for the safe keeping of residents’ personal allowances should residents choose to use this facility. What has improved since the last inspection? What they could do better: The care planning documentation and delivery of care provided was inadequate at times and this prevents the personal, health care and welfare needs of residents from being met. One resident said “ I get no sleep here as there is a lot of noise from upstairs”. Residents must be encouraged to be involved in the agreeing and reviewing of their care plans in order to ensure that their personal preferences and routines are maintained. Activities must be provided for those residents with dementia care needs or for those residents that are either nursed in bed or choose to remain in their bedrooms to ensure that they can maintain their interests and are provided with social and psychological stimulation. The systems in place in respect of the protection of vulnerable adults may not always afford full protection for residents living at the Home and do not always instil confidence in the residents living there. One resident met during the inspection said “ I don’t feel safe living here”. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 Page 7 A large number of residents eat alone at a small table that is brought to their armchair. This matter needs to be reviewed at the earliest opportunity, with a view to increasing the social aspects of mealtimes, by allowing residents to eat with others at a dining table. In a large number of bedrooms it was noted that residents do not have access to a bedside light, with the result that residents either need to have their bedroom light kept on all night or risk waking up in the dark, unable to reach the light. Not all bedrooms had suitable lockable storage facilities, and where these were available, they were found to be unlocked. The Home Manager must undertake a review of these, ensuring that all those residents who wish to lock away personal possessions are issued with a key, in order to promote the independence and dignity of residents. Staff must undertake training about caring for residents with dementia care needs in order to ensure that they can work competently within this role and enhance the lives of those residents with this specific need. There is often communication difficulties between some staff members and the residents and this may, at times prevent residents from being supported by the staff team in a competent manner and residents’ holistic care needs may not be met as a result of this. Remedial action on a number of health and safety and redecoration issues in respect of the premises must be addressed in order to ensure that residents have a safe and comfortable environment in which to live. 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. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 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 Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 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): 2, 3 & 4 Residents are provided with information about the terms and conditions of their stay at the Home. The holistic needs of residents with dementia were not being fully met by the staff working at the Home and training in this area is required to enhance the quality of the lives of these residents. EVIDENCE: Assessments are undertaken by senior staff for all prospective residents using a comprehensive pre admission assessment document, however the senior staff’s knowledge of the information recorded within these was at times found to be poor and residents’ mental health needs were not always identified accurately within these. On admission to Selly Park Care Centre, residents are issued with a comprehensive contract of terms and conditions of residency. Selly Park Care Centre is registered for older people in need of general nursing care, however a large number of residents that had lived there for a period of time had additional dementia care needs. The majority of residents living at Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 Page 10 the Home have complex nursing and medical care needs and are deemed to be very frail and vulnerable. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 Page 11 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 & 11 The care planning documentation and delivery of care provided was inadequate at times and this prevents the personal, health care and welfare needs of residents from being met. Medication is administered in a safe manner. Residents are generally supported in a respectful manner by the staff and this ensures that the residents’ dignity and self esteem are maintained. EVIDENCE: On admission to the Home, assessments are undertaken of residents’ care needs, however not all of these had been completed in full, and the past histories of residents were not always identified within these. Care plans are derived from this information, however there were inconsistencies in respect of the standard of the content of these and care plans had not been written for a resident that had come to live at the Home some eight days prior to the date that the inspection was undertaken. Most care plans were reviewed regularly, however there was no evidence that these were agreed or reviewed with the involvement of the resident and/or their representative. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 Page 12 Care plans did not always identify the specific support required by the staff in order to meet the residents’ care needs, the residents’ preferences in respect of their daily routines and some care plans in respect of acute and chronic health care needs were recorded in poor detail. Care plans were not always written in respect of any mental health and communication needs of residents, despite these areas being identified as particular care needs for the resident during assessment. Wound care evaluations were recorded in good detail, however the care plans in respect of these did not always identify the treatments ordered by the Tissue Viability Nurse. Personal risk assessments for residents had been undertaken, however moving and handling risk assessments must be further developed to include detail of the action to be taken should a resident fall. Daily reports included good detail of the care afforded in respect of residents’ physical health care needs, however did not include information about the activities that the resident had engaged in during that day, in particular regarding those residents who are unable to participate in group activities or the support afforded to those residents with mental health care needs. The majority of residents had been allocated the same General Practitioner, however residents have the option of retaining their own GP on admission to the Home (if the GP is in agreement). Residents have access to other visiting Social and Health Care professionals, including Social Workers, Specialist Nurses and Chiropodists, A Registered Nurse has been allocated by the Primary Care Trust to provide input in to the health care provision of residents living at the Home as part of a pilot scheme. Most residents were suitably dressed and clothing appeared to have been laundered to a good standard. One resident said “ I enjoy living here, I’m looked after well”. Staff were interacting respectfully with residents during the inspection. Personal care records identified that residents were not always completed in good detail and it was therefore, difficult to establish whether this was due to the actual care not being afforded to the resident or that the care staff had failed to document the care afforded correctly. One resident who was being nursed in their bedroom was found to be sitting in an armchair, without any slippers on and without any drinks available. Another resident appeared to be severely depressed, and this had not been identified by the nursing staff and action had not been taken to reduce this resident’s distress. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 Page 13 One resident said “ Some of the nurses are very good indeed, they do the best they can with what they have got”. Another resident said “ I get no sleep here as there is a lot of noise from upstairs”. The accident records identified that a number of residents had fallen from their beds and risk assessments for the use of bed safety rails had not always been undertaken for these residents. As a safety measure, a number of residents were sleeping with their bed mattresses on the floor and this is considered to be both undignified for residents and a moving and handling risk for both residents and the staff attending to their care needs. The majority of medicines were administered accurately in the home, however discrepancies were seen in medicines with a dose higher that one tablet. The Home Manager was keen to introduce staff drug audits to identify and correct this problem. The medication policies were a standard policy from the Organisation and these must be personalised to reflect the good practice seen in the Home. Residents do not have a key to their bedroom, and the majority of residents do not have ready access to a lockable storage facility within their room, although a large number of bedrooms do have a lockable drawer, but these were found to be unlocked. Where lockable drawers were not available, there was generally found to be a lockable area in the upper part of the wardrobe and these were unsuitable for the use of frail residents. Staff had not undertaken training in respect of death and dying. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 & 15 The activities on offer do not meet the needs and expectations of all residents living at the Home. Residents receive a wholesome and varied diet but the staff teams’ lack of knowledge in respect of specific dietary requirements may put residents at risk at times. EVIDENCE: A part time activities organiser is employed at the Home and there was a variety of activities on offer for residents to participate in should they choose including art, films, exercise to music and current affairs. It was clear that a number of residents enjoyed the art and card-making sessions and their work was displayed in the Hobbies room. There were limited trips out side of the Home, however the activities organiser was looking in to rectifying this. A hairdresser visits weekly and Holy Communion is available regularly. Activities were not provided specifically for those residents with dementia care needs. The focus to date appears to have been on meeting the needs of the more able residents. Individual activity plans had not been written for residents, including those residents who are either nursed in bed or choose to remain in their bedrooms and a record of activities undertaken was not maintained. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 Page 15 There did not appear to be any rigid rules or routines in the Home. Residents appeared to be generally satisfied with the catering arrangements in the Home. The lunch time meal was observed and the choice of food appeared to be nutritious and well presented. Food portions were generous and the dining room was bright and cheerful, with dining tables appropriately set. It was noted that a large number of residents eat alone, which reduces their opportunity for social interaction. There appeared to be enough care staff on duty to assist those residents who required help with their meal. It was observed that care staff were offering assistance in a discreet and sensitive way, preserving the dignity of the residents as far as possible. One resident said “ The Chef cooked a curry and it was smashing”. There appeared to be a lack of clarity amongst the care staff about the dietary requirements of a recently admitted resident. Another resident stated that her need for a special diet was not always being met. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The complaints procedure is comprehensive and is accessible to residents and their visitors. The systems in place in respect of the protection of vulnerable adults may not always afford full protection for residents living at the Home and do not always instil confidence in the residents living there. EVIDENCE: A comprehensive complaints procedure was on display in the Home. Since the previous inspection CSCI had received two complaints about the service provided at Selly Park Care Centre in respect of poor health and personal care delivery and poor communications between hospital and the Home’s staff. Whilst these were found to be partly upheld, these were investigated in an appropriate and timely manner by the Organisation to the satisfaction of the complainants. There were no further complaints recorded in the complaints register in addition to these since the previous inspection. The Home Manager undertakes an audit of all complaints received about Selly Park Care Centre. One resident met during the inspection said “ I don’t feel safe living here at times”. A record of compliments received by the Home was available. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24, 25 & 26 In general, Selly Park Care Centre provides a clean and homely environment for residents to live in. A number of health and safety issues in respect of the premises were outstanding and these may pose a risk to the safety of residents living there. EVIDENCE: The internal environment of the Home was, despite the large size of the building, homely in style. The general standard of decoration within the Home was found to be poor in areas, bedrooms and many communal areas were found to be worn, scuffed and generally in need of redecoration. A rolling programme of refurbishment and redecoration was in place, however the Home Manager stated that this had slipped due to the unpreventable absence of the regular Maintenance Person, however, following the temporary employment of a Maintenance Person, the redecoration programme had recently recommenced. The external gardens were well maintained and attractive. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 Page 18 A shower room had been decommissioned within the past year, creating a useful storage space for equipment used at the Home. Bathroom number 2 is in the process of being decommissioned, and was found to be excessively cluttered with items including three hoists for repair, old carpets and pictures. The bath had been dismantled and was positioned at a dangerous angle on the floor and this was brought to the attention of the Home Manager. Repairs were being undertaken in respect of a bedroom that had been damaged due to a flood. A number of residents’ bedrooms were found to be somewhat sparse and lacking in personal possessions. In a large number of bedrooms it was found that residents do not have access to a light switch or bedside light. As a result of this, unless residents choose to keep their bedroom light on throughout the night, they are in darkness and have to call for the care staff for assistance. A written record is maintained in respect of bath water temperatures and the testing of mechanical bathing aids prior to each use, in keeping with good practice. The temperature within the Home was comfortable on the day of the inspection and the Home was found to be clean and tidy. There was however a smell of stale urine within the reception area and ground floor corridor of the Home. Sluicing facilities were appropriately located in the Home for the hygienic cleansing of commode pots. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 Adequate staffing levels are maintained to meet the needs of residents and the Home do not use agency staff which promotes continuity of care. The recruitment practice is robust, however there is often communication difficulties between some staff members and residents living at the Home and this may, at times prevent residents from being supported by the staff team in a competent manner and residents’ care needs may not be met as a result of this. EVIDENCE: The staffing rotas identified that the Home were working within approved staffing levels, however a small number of staff continued to work an excessive number of hours each week, in excess of sixty hours each week by choice on a regular basis and the Inspectors were informed by the Home Manager that plans were in place to reduce this. Agency staff were rarely used at the Home. Kitchen, cleaning, laundry and administration staff provide support for the care staff on duty. During the inspection CSCI received a number of concerns from residents and visitors in respect of the poor comprehension of the English language of a number of staff working at the Home and whilst this was apparent during the inspection, the Inspectors were informed that plans were in place to address these issues. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 Page 20 Staff files included the majority of information required by Regulations, pre employment health declarations are undertaken and new staff are issued with contracts of terms and conditions of employment and job descriptions. There was no evidence of their entitlement to work at the Home in respect of one staff member who had come from overseas. Following the inspection CSCI were informed that evidence of this had since been put in this staff member’s file. The Inspectors were informed that staff working at the Home were deemed to be safe to work with vulnerable adults, however documentary evidence of this was not available at the Home. It is recommended that a record of notes made during prospective staff interviews be kept. The Home Manager had attended a four day training programme arranged by the Organisation in order to provide training in respect of health and safety issues to the staff team. Staff had undertaken training in respect of the protection of vulnerable adults however this did not include Birmingham Multi Agency guidelines and did not clearly state that the Local Authority has the lead role in respect of adult protection. Staff had not undertaken training in respect of caring for residents with dementia care needs. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 & 38 The standard of care provided at the Home is regularly monitored for quality. The systems in place of resident consultation are good. The health, safety and welfare of residents is protected through staff training and maintenance checks of equipment. The staff had failed to investigate an accident affecting the health and safety of a resident living at the Home and this does not afford full protection to this individual and other residents living there. EVIDENCE: The Home Manager had been in post for one year and is in the process of applying for registration as Manager of the Home with The Commission for Social Care Inspection. A full time Care Manager is also employed at the Home. A residents’ meeting had been held recently and the minutes of this was available. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 Page 22 Quality monitoring visits are undertaken regularly by external Managers and reports of the outcomes of these are sent to CSCI. The certificate of employer’s liability insurance on display in the Home on the day of the inspection had expired. The staff do not manage the personal finances of residents, with the exception of the safe keeping of their personal allowances as requested. The system for the management of this was good, separate transaction records were maintained and receipts of all personal items purchased out of residents’ money were available. The account balances of individual money wallets sampled were found to be correct. Health and safety checks of equipment used at the Home are undertaken including the fire alarm system, emergency lighting and thermostatic water valves. Staff had undertaken training in health and safety issues including moving and handling, health and safety, food hygiene and fire safety awareness and a fire drill had been undertaken recently. Accident records were well maintained and audited regularly. It is recommended that any action taken following an accident involving a resident living at the Home be recorded on the accident reports for ease of auditing. The accident book identified that a resident had fallen whilst being attended by staff and an investigation in to how this accident had occurred had not been undertaken by the Organisation. CSCI had not been notified by the Home’s staff about this particular accident and other accidents and incidents involving residents living at the Home as required by Regulations. Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 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 x 3 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 2 x x 2 x 2 3 2 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 x 2 3 x x 2 Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5(1)(2) Requirement The Organisation must ensure that the service user guide includes the views of residents living at the Home and be accessible to all residents. This requirement was not assessed on this occasion. Comprehensive pre admission assessments must be undertaken in respect of all prospective residents to include their holistic care needs and staff must be aware of the content of these. The Organisation must apply to CSCI for a variation to their category of registration in order to regularise the residents currently living at the Home with dementia care needs. Care plans must be written for all residents living at the Home. The Home Manager received this in the form of an immediate requirement The care planning system must DS0000024886.V257835.R01.S.doc Timescale for action 30/02/06 2 OP3 14 30/11/05 3 OP4 CSA 2000 31/12/05 4 OP7 15 28/10/05 5 OP7 15, 17 15/12/05 Page 25 Selly Park Care Centre Version 5.0 be further developed: Care plans must be agreed and reviewed with the involvement of the resident and/or their representative, wherever possible Care plans must be further developed to include more detail of the actual care to be afforded to residents Care plans for acute and chronic health care needs must be written (timescales of 13/12/04, 15/07/05 and 31/07/05 not met) 12(1) The daily report must include 16(2)(m,n) detail of the activities that the resident has engaged in during that day. (timescale of 15/07/05 not met) The daily reports must include any detail of care afforded in respect of the mental health needs of residents Moving and handling risk assessments must be further developed to include detail of the action to be taken should a resident fall (timescale of 31/07/05 not met) On admission to the Home comprehensive assessments of residents’ holistic care needs must be undertaken. Personal care records must reflect the actual care afforded to residents Drinks must be accessible to residents at all times Residents must be supported to DS0000024886.V257835.R01.S.doc 6 OP7 30/11/05 7 OP7 13(5) 15/12/05 8 OP7 14 30/11/05 9 10 11 OP7 OP8 OP8 12(1) 12(1) 12(1)(4) 30/11/05 30/11/05 30/11/05 Page 26 Selly Park Care Centre Version 5.0 12 13 OP8 OP8 12(1) 13(4) 12(4)(a) 14 OP10 12(4)(a) be appropriately dressed and comfortable at all times The nursing staff must identify and support the residents to meet their holistic care needs. Risk assessments for the use of bed safety rails must be undertaken for those residents deemed to be at risk of falling from their bed and appropriate measures must be undertaken to prevent such accidents with residents’ dignity and the health and safety of the care staff in mind Residents’ dignity and comfort must be maintained at all times to ensure that they feel safe living at the Home. (timescale of 01/06/05 not met) Residents must be offered a key for their bedroom door unless their individual risk assessment states otherwise Suitable lockable storage facilities must be available in residents’ bedrooms for their individual use Staff must undertake training in respect of death and dying 30/11/05 30/11/05 30/11/05 15 OP10 12(4)(a) 01/01/06 16 OP10 12(4)(a) 23(2)(m) 18(1) 31/12/05 17 OP11 28/02/06 18 OP12 (timescale of 13/05/05 not met) 16(2)(m,n) Individual activity plans must be 15/12/05 written for all residents, including those residents with dementia care needs and those residents who are either nursed in bed or choose to remain in their bedrooms and a record of activities undertaken must be maintained (timescale of 01/08/05 not met) 16(2)(m,n) Activities must be available specifically for the needs of those residents with dementia care needs and those residents DS0000024886.V257835.R01.S.doc 19 OP12 01/01/06 Selly Park Care Centre Version 5.0 Page 27 20 OP15 12(4)(a) 16(2)(m) 12(1) 21 OP15 22 OP18 13(6) who are unable to participate in group activities Consideration must be given of ways to promote social interactions between residents at mealtimes All staff involved in the serving of meals must be aware of any special dietary requirements of residents living at the Home The whistle blowing policy must be further developed to incorporate the Department of Health guidance, No Secrets to ensure that the person voicing their concerns will be safeguarded The adult protection policy must be further developed to include Birmingham Multi Agency Guidelines This requirement was not assessed on this occasion The Organisation must ensure that the rolling programme of redecoration and refurbishment within the Home continues Surplus equipment must be removed from the former bathroom number 2 or this area must be made inaccessible to residents for reasons of health and safety The Home Manager received this in the form of an immediate requirement Residents must be able to control the lighting in their bedrooms for reasons of health and safety All areas of the Home must be fresh smelling Staff must not work an excessive number of hours each week on a regular basis DS0000024886.V257835.R01.S.doc 15/12/05 30/11/05 01/01/06 23 OP19 23(2)(d) 30/11/05 24 OP19 13(4) 23(2)(l) 28/10/05 25 OP24 23(2)(p) 30/11/05 26 27 OP26 OP27 23(2)(d) 13(4) 18(1) 30/11/05 03/11/05 Selly Park Care Centre Version 5.0 Page 28 (timescale of 31/07/05 not met) The Home Manager received this in the form of an immediate requirement The Organisation must ensure that all staff working at the Home have a good comprehension of the English language in order to communicate effectively with residents living there The Organisation must ensure that plans are in place for the care staff to work towards the NVQ Level 2 qualification in care This requirement was not assessed on this occasion Evidence of satisfactory criminal records clearance for all staff must be available at the Home Staff training in respect of the protection of vulnerable adults must include Birmingham Multi Agency guidelines Staff must undertake training in respect of caring for residents with dementia care needs The Home Manager must complete her application for registration with The Commission for Social Care Inspection (timescale of 31/07/05 not met) Residents’ service satisfaction surveys must be undertaken and an annual report based on the findings of these must be produced This requirement was not assessed on this occasion All care staff must receive formal supervision at least six times per year DS0000024886.V257835.R01.S.doc 28 OP27 18(1) 31/12/05 29 OP28 18(1) 01/02/06 30 31 OP29 OP30 13(6) 13(6) 30/11/05 31/12/05 32 33 OP30 OP31 18(1) 9 31/12/05 15/12/05 34 OP33 24 15/01/06 35 OP36 18(2) 15/01/06 Selly Park Care Centre Version 5.0 Page 29 This requirement was not assessed on this occasion 36 OP38 37 CSCI must be informed of all 27/10/05 incidents and accidents affecting the health, safety or welfare of residents living at the Home The Home Manager received this in the form of an immediate requirement All staff must perform safe moving and handling techniques following the instructions within the resident’s moving and handling assessment (previous timescales of 13/10/04 and 31/05/05 not met) A risk assessment must be undertaken in respect of holding bedroom doors open until suitable magnetic closures that are linked in to the fire alarm system can be fitted This requirement was not assessed on this occasion 37 OP38 13(5) 30/11/05 38 OP38 23(4) 30/11/05 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 OP9 OP9 Good Practice Recommendations Staff drug audits before and after a drug round must be undertaken to confirm staff competence in medicine administration The medication policies should be rewritten to reflect the good practice within the home and be personal to the Home DS0000024886.V257835.R01.S.doc Version 5.0 Page 30 Selly Park Care Centre 3 OP29 It is recommended that a written record of any notes made during prospective staff interviews be kept. A current certificate of employer’s liability insurance should be on display in the Home It is recommended that receipts of personal items purchased out of residents’ money are numbered for ease of auditing. It is recommended that any action taken following an accident involving a resident living at the Home be recorded on the accident reports for ease of auditing. 4 OP34 5 6 OP35 OP38 Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Selly Park Care Centre DS0000024886.V257835.R01.S.doc Version 5.0 Page 32 - 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. 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