Inspection on 31/05/05 for Selly Park Care Centre

This inspection was carried out on 31st May 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 27/10/05

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 B29 7HW Lead Inspector Amanda Lyndon Unannounced 31st May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Selly Park Care Centre Address 95a Oakfield Road Selly Park Birmingham B29 7HW 0121 471 4244 0121 471 1107 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ashbourne Healthcare Care Home with Nursing 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. 50 general nursing care. Males and females over the age of 65 years. 2. That the home is registered to accommodate one named service user under 65 years of age, who is in need of long term nursing care. Date of last inspection 13 October 2004 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 its 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 E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken by one Inspector during an afternoon and evening, and was assisted throughout by the General Manager. There were 40 residents living at the home on the day of the inspection. Information was gathered from speaking with the residents, visitors and staff, observing the care staff perform their duties and examining care and medication records. Since the previous inspection CSCI had received two complaints about Selly park and the home had investigated a further three complaints. These were mainly in regard to the standard of care afforded to residents in respect of their health and personal care needs and the recorded management of this. Whilst a number of these were upheld, changes in practice had been instigated at the time of this inspection to improve the standard of care provided by the home. What the service does well: Selly Park Care Centre provides a homely, comfortable, clean and safe environment for residents to live in. Residents can personalise their bedrooms to reflect their individual tastes to ensure that they feel comfortable in their surroundings and are supported in a respectful manner by the staff working at the home. Despite poor care planning documentation, residents were generally well supported by the nursing and care staff to meet their health, welfare and personal care needs and medication is administered in a safe manner. One resident said, “ If I need any help, I press my buzzer and the staff come and help me”. There are a variety of activities on offer at the home for the residents to participate in should they choose. Residents are offered a choice of wholesome, nutritious and well-presented meals and special dietary requirements are catered for. One resident said “ There are always two choices of main meals at lunchtime and if you don’t like either of those, you can have a salad or lighter snack.” Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 6 There is a comprehensive complaints procedure accessible to residents should they need to make a complaint and group meetings are also 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. The home do not use agency staff and provide appropriate training for their staff team to ensure that they have the knowledge to work within their job roles. What has improved since the last inspection? What they could do better: Whilst each resident had a care plan, this did not always describe the actual care to be given by the care staff to meet the person’s identified care needs. Although residents’ health and welfare needs were generally met, the nursing staff had, on occasion failed to instigate referrals to other Health Care Professionals as required. Activity plans must be written for all residents living at the home including those who are nursed in bed and take their interests into account. . One resident said, “ At present we don’t have an activities person but every fortnight we have an exercise class”. A supper time snack meal is not offered to residents living at the home and therefore there is an unacceptable length of time between when tea is served and when breakfast is served the following morning. The chairs in the communal lounges were not arranged to promote social interaction between residents and up to date popular music was being played Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 7 in one of the communal dining areas and this may not have been the preferred choice of radio channel of the residents living at the home. Staff stated that there were not enough staff members on duty to assist all of the residents living at the home at mealtimes; however, this did not appear to be the case on the day of the inspection. 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 E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 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 standard(s) 3 & 4 Residents are accepted to live at Selly Park Care Centre following an assessment to ensure that the home can meet their care needs and these needs are kept under review, and through visits are able to make an informed choice about whether or not they wish to live in the home. EVIDENCE: All prospective residents are assessed prior to coming to live at the home using a comprehensive preadmission assessment document and are invited to have lunch at the home with other residents. Prior to this inspection CSCI had received a complaint about a resident being admitted to the home without appropriate equipment being in place for the resident to use, however at the time of this inspection the General Manager had instigated changes in pre admission procedures at the home and this was no longer problematic. Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 10 There continued to be a number of residents living at Selly Park Care Centre with dementia care needs and the home does not have a category of registration for this, however since the previous inspection, the home had not accepted any people to live at the home with dementia care needs. Staff had received training in respect of dementia care needs and residents are reassessed should their care needs change in order to ensure that the home can continue to meet their needs. Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 & 10 Despite poor documentation detailing care needs, residents were generally well supported by the nursing and care staff to meet their health, welfare and personal care needs. Medication is administered in a safe manner, however not all medication is stored securely which may pose a risk to residents’ safety. Residents are generally supported in a respectful manner by the staff working at the home and this ensures that the residents’ dignity and self-esteem are maintained. EVIDENCE: On admission to the home, assessments are undertaken of the individual’s care needs and care plans are derived from these assessments however, improvements were required in respect of this. Care plans were not always reviewed monthly and the evaluations were often non descriptive and did not provide evidence that the care needs were being monitored. Care plans were not written and reviewed with the involvement of the resident and/or their representative. The care plans were generally comprehensive but a number of these must be further developed to include more detail of the actual care to be given to the Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 12 individual. Care plans for acute health care needs were not always written, therefore there was no evidence that a number of health care needs were being monitored by the nursing staff and this included no plan of wound care treatment for a resident following the advice of the Tissue Viability Nurse. Personal risk assessments had been undertaken and were reviewed monthly including the risk of falls, nutrition and moving and handling, however this required further development to include detail of the type of hoist and size of sling to be used if necessary and the action to be taken should a resident fall. Assessments of the risk of the development of pressure sores had been undertaken, however a written record of the type of pressure relieving equipment provided for individual residents was not kept. Appropriate pressure relieving equipment was available for residents’ use following assessment on the day of the inspection. Residents were weighed monthly and a record of weight loss or gain was maintained. A daily report was written about each resident however a number of these were found to be non informative and did not include detail of the activities that the resident had engaged in during that day. Due to the size of the home, staff allocation records are used to highlight which resident each member of staff had responsibility for throughout the shift and this system appeared to be effective. One resident said, “ If I need any help, I press my buzzer and the staff come and help me”. The home had recently undertaken an audit of the usage of bed safety rails and the care staff had closely monitored the residents who had previously been assessed as requiring these to determine whether they still required them. The medical advisor for the home has given Ashbourne Healthcare her intention to withdraw her services from Selly Park Care Centre therefore, the home and Primary Care Trust are actively seeking another General Practitioner to fulfil this role. The Inspector saw that a resident had been nursed in bed since coming to live at the home as the nursing staff were unsure whether the resident would be able to safely sit in a chair. An Occupational Therapy and Physiotherapy referral must be made for this resident in order to improve their quality of life. The system for the safe mangement of medication was generally robust with the exception of a sputum pot full of “ refused medication” awaiting disposal which was found by the Pharmacist in the treatment room. By collecting all of the tablets together in one receptacle, an accurate audit of medication received into the home and medication returned to the Pharmacy for disposal could not Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 13 be undertaken. In addition these tablets were not stored securely and all medication awaiting return to pharmacy must be stored securely in a locked cupboard. The procedure for the administration of medication was safe. The Inspector saw that a resident was sitting in the lounge with bare feet and was informed by the staff that their slippers were in the laundry. An alternative means of covering the residents’ feet should have been sought in order to preserve the resident’s dignity and comfort. The General Manager stated that although appropriate locks were not available on all bedroom doors, these are being fitted as and when the bedrooms become vacant to ensure that all residents coming to live at the home have the option of whether to lock their bedroom doors. Appropriate privacy locks were fitted to bathroom and toilet doors, which could be over ridden in the event of an emergency, and a lockable storage facility was available in residents’ bedrooms. Privacy curtains were fitted within shared accommodation and the pay phone was located in a quiet area of the home. Staff were interacting respectfully with residents during the inspection. Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 & 15 There is a variety of activities on offer at the home, however these do not meet the needs of those people who are nursed in bed. Residents receive a wholesome and varied diet which meets any special dietary needs, however, residents are not offered a snack meal at suppertime and this may pose a risk to residents’ health. Residents are able to exercise limited choice and control over their daily activities and when they eat. EVIDENCE: The home was in the process of recruiting a new activities organiser however until the post was filled staff working at the home were responsible for organising activities. A hairdresser visits weekly and Holy Communion is held at the home regularly. One resident said, “ At present we don’t have an activities person but every fortnight we have an exercise class”. Other activities on offer included painting, trips out to the shops and pub and bingo. A record of activities provided at the home was not maintained. The Inspector saw that the bedroom door of a resident who is nursed in bed for long periods of time was kept shut, the television or radio was not on in the bedroom and an activities plan in respect of this person had not been written No plan was in place to identify the residents wishes and plan for supervision or activity were apparent. Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 15 The home has an open visiting policy at all reasonable times and visitors met during the inspection stated that they were made to feel welcome at the home. Residents bedrooms contained personal items that reflected individual’s tastes and preferences. Up to date popular music was being played in one of the dining lounges during the tea time meal and this may not be the preferred choice of radio channel of the residents and residents should be consulted about this. The meals served were wholesome and well presented and the portions of the pureed diet were served separately, in keeping with good practice. There are 15 hours between the time that tea is served and when breakfast is served the following morning and a supper time snack meal was not available in the home on the day of the inspection. Staff confirmed that supper time snack meals are not offered to residents. This is wholly unacceptable and may pose a risk to residents’ health, for example for those people who have diabetes. One resident said “ There are always two choices of main meals at lunchtime and if you don’t like either of those, you can have a salad or lighter snack.” A daily record of food eaten by each resident was kept. Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 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 standard(s) 16 The complaints procedure is comprehensive and is accessible to the residents. EVIDENCE: There was a comprehensive complaints procedure on display in the home to ensure that all residents and visitors were aware of how to make a complaint should the need arise. Since the previous inspection there were five complaints recorded in the complaints log and CSCI had investigated two of these, one was of an anonymous nature. The complaints were mainly in regard to the standard of care afforded to residents in respect of their health and personal care needs and the recorded management of this. Whilst a number of these were upheld, changes in practice had been instigated at the time of this inspection to improve the standard of care provided by the home. Records indicated that when complaint investigations found that complaints were upheld, staff training was initiated by the home to address the shortfalls. All internal investigations undertaken were found to be comprehensive. A record of compliments received by the home was available. Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 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 standard(s) 19, 20, 25 & 26 Selly Park Care Centre provides a homely, clean and comfortable environment for residents to live in and a new sluice facility is available on the ground floor of the home and this ensures that the health and safety is maintained. The placement of chairs in the communal areas of the home does not promote social interaction between residents. EVIDENCE: The internal environment of the home was, despite the large size of the building, homely in decoration and style. Carpets and other furnishings were of a good quality and a programme of re decoration was in place. The external grounds were colourful, attractive and well maintained. The home employs a maintenance person. Space was limited in both of the main lounges and the chairs had not been arranged to promote social interaction between the residents on Oak Wing, with chairs placed in rows. Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 18 The temperature within the home was comfortable on the day of the inspection. Each radiator was of a low surface type and could be adjusted manually. Thermostatic valves had been fitted to hot water outlets and the weekly checks of hot water throughout the home identified that the water temperatures did not exceed safe limits. The home was found to be clean and fresh on the day of the inspection and a new commode pot disinfector and sluice facility had been created on the ground floor since the previous inspection. An effective and hygienic laundry service for service users’ clothing and bed linen was in place. Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 There is a robust system for staff recruitment at the home which protects the residents’ safety. Staff undertake training to improve their knowledge of caring for older people and to ensure that they are competent to perform within their job role. Staffing levels are maintained as required, however a number of staff stated that there is an inadequate number of staff on duty during residents’ mealtimes to assist residents’ with their meals. EVIDENCE: Staffing rotas identified that the home were working within approved staffing levels and the rotas sampled indicated that, with the exception of a small number of staff members, staff were not working excessive hours on a regular basis. Ancillary support was provided each day by cleaning, kitchen and laundry staff. One resident said “ The home doesn’t use agency staff anymore, there is enough staff now”. A number of staff stated that a high number of residents required the assistance of the care staff at mealtimes and the staffing levels at mealtimes were not adequate for this. The home appeared to be calm and well organised during the teatime meal on the day of the inspection and in addition plans are in place for a feeding assistant to commence employment at the home. Eleven care assistants had achieved the NVQ Level 2 qualification which is 27.5 of the relevant workforce. Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 20 Staff files sampled included all pre employment information required by Regulations and this included satisfactory criminal record bureau checks. All staff are given a job description and a statement of terms and conditions of employment. Selly Park Care Centre employ two training staff, and care staff had received training specific to the role that they perform including the prevention of falls, continence promotion, infection control, nutrition, tissue viability and resident welfare. Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32 & 38 A Group of residents are regularly consulted about the service provided at the home, but no arrangement s are in place to consult with all other residents. Staff have received training in respect of health and safety issues however this guidance is not always followed and residents’ safety may potentially be at risk because of this. EVIDENCE: The General Manager has been in post for seven months and is yet to apply for registration as Manager of the home with The Commission for Social Care Inspection. She is working towards the Registered Managers Award and is a Registered Nurse with a live registration who has had previous experience within management roles. In addition the home employ a full time Care Manager to support the General Manager. One visitor met during the inspection stated, “ The Manager is always available to talk to when we visit here”. Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 22 Communication between the General Manager and the staff team had improved since the previous inspection with the use of communication books and posters and in addition staff meetings are held regularly and the minutes of these were available. A residents’ meeting had been organised recently however the uptake of this was poor. The General Manager stated that this may be because the meeting was not advertised prominently in the home, therefore, plans are in place to arrange another meeting and residents will receive an individual invitation to attend. Plans are also in place for an informal meeting to be arranged with relatives and residents at a weekend. Visits to the home by the Regional Manager are undertaken regularly and a report of this is forwarded to CSCI each month. Only one side of the certificate of registration was on display and both pages must be displayed. Health and safety checks in respect of emergency lighting and fire safety equipment were maintained as required. The home has a health and safety committee and the minutes of their regular meetings were available. The majority of staff had received mandatory training in health and safety issues including fire awareness, health and safety and basic food hygiene and an ongoing programme of this was in place. Staff had undertaken training in safe moving and handling practices, however, the Inspector saw two care assistants perform an unsafe moving and handling technique and this was brought to the attention of the General Manager. To ensure that residents’ safety is maintained a risk assessment is to be undertaken in respect of holding bedroom doors open until suitable magnetic closures that are linked into the fire alarm system can be fitted. Accident records were found to be fully detailed, well maintained and are audited regularly by senior management. Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION 3 2 x x x x 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 3 x x x x x 2 Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 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 Registered Provider must ensure that the service user guide includes the views of residents living at home and be accessible to all residents. This requirement was not assessed on this occasion and will be carried forward The statement of terms and conditions of residency must include details of any additional services to be paid for that are excluded from the fees. This requirement was not assessed on this occasion and will be carried forward The care planning system must be further developed : Care plans must be reviewed at least monthly Care plans must be written and reviewed with the involvement of the resident and/or their representative, wherever possible. (timescale of 13 December 2004 Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 25 Timescale for action 30 September 2005 2. OP2 5(1)(c ) 30 September 2005 3. OP7 15(1) 17(3) 12(2)(3) 31 July 2005 not met) 4. OP7 12(1)(2)( 3) 15(1)(2) Care plans must be further developed to include more detail of the actual care to be given to the individual. Care plans for acute health care needs must be written. Personal risk assessments must include more detail, for example a written record of the type of pressure relieving equipment or hoisting equipment for individual residents must be kept. The daily report must be recorded in more detail and include information about the activities that the resident has engaged in during that day. Moving and handling risk assessments must be further developed to include detail of the action to be taken should a resident fall. All staff must perform safe moving and handling techniques as per the residents moving and handling assessments. (timescale of 13 October 2004 not met) The General Manager received this in the form of an immediate requirement Occupational Therapy and Physiotherapy referrals must be made for residents as required in order to improve their quality of life. The General Manager received this in the form of an immediate requirement All medication awaiting return to the Pharmacy must be stored securely in a locked cupboard 15 July 2005 5. OP7 12(1)(2)( 3) 15(1)(2) 15 July 2005 6. OP7 12(1)(2)( 3) 16(2)(m)( n) 13(5) 15 July 2005 7. OP7 31 July 2005 8. OP38 13(5) 31 May 2005 9. OP8 12(1)(2)( 3) 6 June 2005 10. OP9 13(2) 1 June 2005 Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 26 and all medication ready for return must be identifiable and accounted for in order for accurate medication audits to be undertaken. (Previous immediate requirement timescale of 14 October 2004 not met) The General Manager received this in the form of an immediate requirement 12(4)(a) Residents dignity and comfort must be maintained at all times. 18 (c ) (1) The home trainer must access (i) training for staff in respect of death and dying. (timescale of 13 May 2005 not met) The home must ensure that individual activity plans are written for all residents and maintain a record of the activities as they have been undertaken. Residents must be consulted about the choice of music playing in communal areas of the home. A snack meal must be offered in the evening and the interval between this and breakfast the following morning must be no more than 12 hours. The General Manager received this in the form of an immediate requirement 16. OP18 13(6) The whistleblowing 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. 31 August 2005 11. 12. OP10 OP11 01 June 2005 31 October 2005 13. OP12 16(2)(m)( n) 01 August 2005 14. OP14 16(2)(n) 30 June 2005 2 June 2005 15. OP15 16(2)(i) Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 27 The adult protection policy must be further developed to include Birmingham Multi Agency guidelines. Staff must receive training in respect of adult protection to ensure that they are aware of their responsibilities regarding this. This requirement was not assessed on this occasion and will be carried forward 17. OP20 16(2)(m)( n) 18. OP27 18(1)(a) 19. OP27 18(1)(a)( 2) 20. OP28 18(1)(c )(i) 21. OP31 9 22. OP33 24(1)(a)( b)(2)(3) The chairs in communal areas of the home must be arranged to promote social interaction between the residents on Oak Wing. The General Manager must undertake a review of staffing levels during meal times mindful of the dependencies of residents living at the home. The General Manager must undertake a review of staff working an excessive amount of hours per week and implement plans to reduce this. The Registered Providers must ensure that plans are in place for the care staff to work towards the NVQ Level 2 qualification in care. The General Manager must apply for registration with The Commission for Social Care Inspection. Residents service satisfaction surveys must be undertaken and an annual report based on the findings of these must be written. 31 July 2005 15 July 2005 31 July 2005 30 September 2005 31 July 2005 31 October 2005 Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 28 23. 24. OP34 OP36 This requirement was not assessed on this occasion and will be carried forward. CSA 2000 All pages of the certificate of Section 28 registration must be on display in the home. 18(2) All staff must receive formal supervision at least six times per year. This requirement was not assessed on this occasion and will be carried forward The following policies and procedures must be further developed: Accident Fire Safety Missing Persons A policy on cross gender and intimate care must be written This requirement was not assessed on this occasion and will be carried forward A risk assessment is to be undertaken in respect of holding bedroom doors open until suitable magnetic closures that are linked into the fire alarm system can be fitted. The General Manager received this in the form of an immediate requirement 15 July 2005 30 September 2005 25. OP37 17 31 October 2005 26. OP38 23(4) 14 June 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP35 Good Practice Recommendations It is recommended that receipts of personal items E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 29 Selly Park Care Centre purchased out of residents money are numbered for ease of auditing. This recommendation was not assessed on this occasion and will be carried forward. Selly Park Care Centre E54_S24886_Sellypark_V230578_310505 - Stage 4.doc Version 1.30 Page 30 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45/46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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