Inspection on 04/10/06 for Selly Park Care Centre

This inspection was carried out on 4th October 2006.

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 18/09/07

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 Key Unannounced Inspection 4th October 2006 09:20 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.V315560.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.V315560.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.V315560.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 24th April 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 small reception area, which includes display information, notice boards containing information about current events and a copy of the latest CSCI report is also accessible. The current scale of charges for the home range from £314.00 to £461.00 per week. Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork was carried out over a period of nine hours; assistance was supplied by the registered manager throughout. There were 41 residents living at the home on the day of the visit. Information was gathered from speaking with residents, two healthcare professionals and staff including two staff interviews. Care, health and safety and the arrangements for the administration of medications were examined. Staff personnel files were checked and staff were observed whilst performing their duties. A partial tour of the premises was undertaken. The manager confirmed that a pre-inspection questionnaire had been completed and posted to CSCI; unfortunately it had not arrived at the CSCI office. Seven comment cards have been received from relatives. At the conclusion verbal feedback was given to the registered manager and the operations manager. What the service does well: Residents reported their overall satisfaction with the home and the standards of care provided by staff. Comments received from one resident included, “Staff treat me well, if I had a problem I would go to Linda’s office. I can talk about anything at the residents meetings.” The arrangements for the administration of medications are robust ensuring that residents receive the prescribed medications to promote their well being. The registered manager displayed a transparent approach and is supported by a care manager who caries out administration duties one day each week to contribute to the day to day operations of the home. The registered manager has regular meetings with the operations manager who supplies further support and guidance for the management of the home. There is a good mechanism for the safekeeping and financial transactions of monies held on behalf of residents ensuring that they are protected from the risk of financial abuse. Adequate and consistent staffing levels are maintained and the lack of use of agency staff promotes continuity of care for residents. Regular monitoring of the dependency levels of residents are carried out to confirm that there are sufficient staff to meet residents needs. Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 6 Residents and relatives meetings are held regularly and this enables them to voice any concerns and to express opinions about how the home is run and could be improved. A Primary Care Trust assessor continues to have regular input within the home and ensures that specialist equipment is provided to treat the health needs of residents. What has improved since the last inspection? What they could do better: Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 7 The home needs to complete the already commenced work in ensuring that Moving and Handling, Health and Safety, Food Hygiene and Fire Safety training is supplied to staff by accredited trainers. This ensures that staff have the knowledge and skills to meet the needs of residents. 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.V315560.R01.S.doc Version 5.2 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.V315560.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive written documents are available to enable prospective residents to make an informed decision about living at the home. Preadmission assessments are carried out to ensure that the home is able to meet individual’s needs. EVIDENCE: The contents of the statement of purpose and service user guide provide sufficient information about the services of the home and both documents are readily available at reception for visiting people to read. A copy of the latest CSCI inspection report is also on display at reception. Each bedroom includes a file containing a copy of the service user guide, samples of the activities and meals provided as well as other information to ensure that all residents have continuous and easy access to information about the standards they can expect to receive. The service user guide is also Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 10 available in audio cassette format for the convenience of persons who are visually impaired. The home is commended for this initiative. The tool used by senior staff to carry out pre-admission assessments includes a section for the recording of recreational preferences. Examination of completed tools indicated that assessments are comprehensive, which confirms the homes ability to meet peoples identified needs. Advice was given that the home carries out further assessments when a resident has been in hospital and is ready to be discharged to confirm that the possible increased needs can still be met by the home. The home does not provide intermediate care. Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Good improvements have been achieved in respect of care planning but further work is needed to ensure that all care needs are being met. The arrangements for the administration of medications are robust and protect residents from the risk of harm. EVIDENCE: Each resident has a written plan of care. This is individualised and identifies assessments carried out and how staff should provide care to promote the health and well being of residents. The recently introduced new care planning system provides scope for significant improvements and on the whole this was evidenced. It was noted that care plans have been agreed and signed by residents or respective relatives. Care plans include some good details for staff to follow, for example, ‘prefers to have meals in his own room’; this promotes residents to make their own decisions about how they wish to live in the home. Files provide good Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 12 information about a range of assessments, which are reviewed regularly and any changes of needs are recorded. All trained and care staff have recently attended training in care in death and dying to ensure that the care in later life is comprehensive and dignified. Pressure ulcers are appropriately recorded to enable staff to monitor them. There was good evidence of the services of a tissue viability nurse and staff appeared to be carrying out the instructions given to them. Specific details are recorded about the continence needs of individuals but the proposed programme of toileting must be made clear to provide staff with guidance on how often this should be carried out. Some of the files seen indicated the frequency of position changes of residents to prevent the occurrence of pressure ulcers. The recordings on charts in the respective rooms indicated that staff were complying with the instructions within the care plans. Mobility assessments are carried out for all residents and staff instructions are provided. The home needs to record the sling size needed for individuals who require transfer via a hoist to enable staff to carry out the procedure correctly. One care plan seen recorded that the resident can stand for a short period of time but later instructs staff to carry out all transfers by hoist. This restricts the resident from maintaining his/her independence. Staff need to be mindful about use of terminology such as ‘drawer sheets’ as this is misleading. The home needs to expand on the scheme for recording nighttime preferences to include all daytime preferences to ensure 24 hour arrangements are in place and are actioned by staff. Some residents have dementia and may display difficult to manage behaviour. The home needs to further develop this area of care planning to include details of the possible trigger and type of behaviour displayed and advise to staff on how to deal with the situation to diffuse it as effectively as possible for the benefit of the resident and others who may be in the vicinity. Resident’s files included comprehensive details about many visiting healthcare professionals and instructions for staff to follow to promote resident’s health and well being. A resident advised, “I go to the hospital three times a week”. Feedback received from residents included, “You won’t find any complaints here, staff treat me well, everyone is so friendly, I love all the nurses, everyone is so kind”. During the fieldwork visit a doctor visited the home to leave five information packs for residents. The home with resident’s permission has agreed to take part in a survey about coping with pain. The registered manager was advised that feedback would be given to the home about the results. This is viewed as a positive approach to improving care for residents. Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 13 The arrangements for the receiving, administration and disposal of medications were found to be good. The recordings made on MAR (medication administration record) charts included auditing of medications received and the reverse of the charts have been used to quantify why a medication has not been administered. The good management of medications safeguards residents from potential harm. Staff were observed using the preferred term of address towards residents. Personal care was delivered in the privacy of bedrooms or bathrooms to preserve residents dignity. Selly Park Care Centre DS0000024886.V315560.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. The home provides well organised, varied social activities that meet the expectations of residents providing them with interest and pleasure. Residents are able to exercise choices over their daily routines and staff promotes individuality and independence. A wholesome and varied diet is offered, which meets specialist dietary needs. EVIDENCE: The programme of in-house activities is on display and offers a varied range of sessions morning and afternoons covering seven days per week. Other events include a weekly visit to a local pub, hairdressing, outings to parks and regular visits from a range religious clerical officers to meet residents spiritual needs. An activity was observed in progress. This constituted three visiting personnel who played musical instruments and sang old time songs. Two residents had been given castanets and were observed joining in with the music and singing. There was a positive atmosphere in the room and residents carried on singing long after the entertainer’s departure. The activities organiser was present throughout and was noted spending time with residents who remained in their Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 15 bedrooms. At the end of the event the entertainers and activities organiser were seen chatting and waving to residents in the lounge. A resident informed that he feeds the birds and fish every day and looks after the potted plants. Another advised, “I go to town every Friday to do some shopping, I get the bus”. Another resident said that she goes to relatives for Christmas day. Any donations made to the home are put into the residents fund for the purchasing of Christmas presents or used towards further fund raising, and residents decide on how it should be spent. Residents discuss the programme of in-house recreations and outings during their regular meetings. The minutes of the meetings are on display at the reception area. These indicate that residents discuss the meals provided and make suggestions about the day to day operations of the home. The registered manager holds a ‘surgery’ every Wednesday evening for residents and family to discus any issues or concerns. This indicates that residents influence the running of the home. A non European resident was spoken with, there were obviously no problems encountered in communications with staff who were later observed joking with the resident. The home’s menu indicates that residents are offered a varied, nutritious and balanced diet. There was good evidence that choices are offered to residents, they confirmed this during discussions. One resident of ethnic minority said that he prefers to have English meals and staff advised that they regularly offer culturally appropriate meals but the resident declines. Kitchen staff are experienced in preparing culturally appropriate meals when required. Information given was that one resident has chosen to have a cooked breakfast every day. Care plans indicated those people who prefer to have their meals in bedrooms or in one of the lounges. There is also a choice of two dining rooms; both provide a pleasing environment with ample space for access by wheelchair users. The tables were attractively laid. Lunch was observed being served in both dining rooms and the lounges. The main courses were attractively served by catering staff from hot trolleys located in each dining room. Staff were observed providing discreet assistance to ensure that residents enjoy the experience whilst ensuring their dignity is maintained. Soft and pureed meals were served in a satisfactory manner to promote the residents enjoyment of the meal. Comments received from a resident were, “I really enjoyed that”. Relatives are invited to share a meal with their respective resident and staff invite them to make comments about the standard of the meals provided. Care staff served the desert, but it was noted that the hot pudding had been removed from the hot trolley in the small dining room and left on a cold trolley well before residents had completed the main course. The home must ensure that all courses are served at the appropriate temperature to promote residents enjoyment of the meal. Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 16 The evening meal was served by care staff and looked appealing and is accompanied by fresh salads. A range of cold foods and light cooked meals are offered. Night staff offers snacks to residents. Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents and relatives are confident that their views will be listened to and are aware of how to make a complaint. The written policy regarding adult protection requires amendment to give clear advice to staff of the action to be taken in the event of an allegation of abuse. EVIDENCE: There is a comprehensive complaints procedure, which is accessible to residents and their representatives, should they wish to make a complaint. Residents indicated their awareness of how to make a complaint during discussions held with them. The comment cards received from relatives indicate that they are aware of how to make a complaint. CSCI has not received a complaint about the home since the last visit was made. The home has not received any formal complaints since the last two inspections; this is an indicator that residents are satisfied with the standards of the services provided for them. All staff have received training in adult abuse and protection of vulnerable adults. Staff spoken with demonstrated a good understanding of their roles in this capacity in protecting residents from the risk of harm and what they should do if abuse is suspected. The written policy requires amendment Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 18 regarding the prime agency to be informed. Although the operations manager needs to be made aware of concerns raised consultation and the registered manager carrying out an investigation should not occur unless instructed to do by the adult protection team. Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 19 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, 22, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with warm, comfortable, hygienic and well maintained accommodation, which includes specialist equipment to enable needs to be met. EVIDENCE: The interior of the home provides a warm and pleasing environment with a number of lounges and dining rooms for residents to choose from. Residents and their family can also use the activities room on the first floor as a quiet room. The home has a maintenance programme for ongoing improvements to be carried out. There are two attractive gardens for residents and visitors to frequent. Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 20 There are assisted bathing in the form of baths and showers are available for residents to choose the type of bathing they prefer. Communal toilets are located throughout for ease of access. The Primary Care Trust officer advised that the equipment needed for the current residents has been provided. This includes pressure relieving equipment. The home has a number of mobile hoists, which assists in the safe transfer of residents to bathrooms, communal rooms and their bedrooms in order to enhance the quality of their lives. The home is also equipped with two shaft lifts and a call system in all rooms. The nurse’s office is situated between the two smaller lounges and this facilitates observations of residents in those lounges. There are 34 single bedrooms; three have en-suite facilities and eight shared rooms. Although the home is registered to accommodate 50 people they have voluntarily restricted this to 45 persons. All rooms have bedside lamps, a lockable facility for security of valuables and suited door locks to ensure privacy. The rooms of the persons whose care plans were seen were visited t ensure that the required equipment was in place. They were homely in appearance and there was evidence of personal belongings and items of furniture that residents have taken into the home. A comment made by a resident was, “I’ve got a lot of stuff in my bedroom”. The home was clean and tidy throughout including the kitchen and laundry rooms. There was no evidence of a mal odour. Random hot water temperature checks were being regularly carried out for all outlets that residents have access to prevent the risk of scalds. Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels are maintained to meet the needs of residents. The home operates a robust system for the recruitment of staff to protect residents from risks of harm. Some staff training is needed to supply them with the knowledge and skills to carry out their roles efficiently. EVIDENCE: Four recent weeks of the staff rota were examined; these appear to provide adequate staffing levels for each shift. A complement of ancillary staff are employed to cover seven days a week. A maintenance operative is employed part time and an administrator work full time. These arrangements ensure that staff are able to carry out their designated roles. The home does not use agency staff. Checking of staff personnel files indicated that all necessary checks are carried out and references sought before an applicant is offered a position. This indicates that resident’s safety is paramount. Newly employed care staff undertake the Sills For Care induction programme as well as the homes own course to enable them to carry out their roles effectively so far. Although few staff have successfully completed NVQ level 2 training a further 17 have enrolled to do the course. The home had previously received training in Moving and Handling, Fire Safety, Health and Safety and Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 22 Food Hygiene by trainers who were not accredited to carry out this work. Since the last visit the home has made good progress in ensuring that training is being supplied by appropriate trainers but has not fully completed the work. The registered manager assured that the training would be completed as soon as possible. It was pleasing to note that the majority of care staff have received training in dementia care and other courses are offered to some staff that reflect the specialist needs of residents. Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 23 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, 36 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 is experienced and has the skills to oversee out the day to day operations of the home. Regular audits are carried out to ensure that the standards of the home are monitored and improvements actioned. The health and safety arrangements are good and protect residents from the risk of injuries. EVIDENCE: The registered manager is experienced and is keen to make continuing changes to the home for the benefit of residents. She displayed a transparent approach to residents, visitors and staff and delegated tasks in constructive manner. Discussions held with staff indicated that they are well supported. By the management structure. Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 24 The registered manager has commenced development of files; one for each of the seven sections of the care standards that provides the documentary evidence of haw each standard is being met. The home is commended for this. The home carries out a vast range of monthly audits of the premises, care plans, accidents, social activities, the kitchen and the finances. Questionaires are sent out to residents and their families three times a year. Advice was given that an annual report needs to be developed to encapsulate all this work and where shortfalls are identified a timescale allocated for the resolution. This will provide the evidence that the home is constantly striving to improve the services provided. The process for the safekeeping and management of financial transactions of personal monies held on behalf of residents is comprehensive and prevent the risk of financial abuse. All trained nurses and care staff now carry out regular formal supervisory meetings with the registered manager to promote their knowledge and skills in carrying out their role for the benefit of residents. The accident records are good and there is evidence of action taken to reduce risks where a trend has been identified. The home carries out the relevant checks and servicing of equipment to ensure that it is fit for purpose. The maintenance operative carries out regular checks on hot water outlets, fire alarms, emergency lighting and the integrity of the fire doors. Fire drills are also carried out and the names of staff participating are documented. The arrangements in place appear to protect residents and others form the risk of injury. Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 25 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 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 3 3 x 3 x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x 3 3 x 3 Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 26 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 toileting regimes must be specific to give staff accurate guidance. The care plans pertaining to personal preferences of daily living need to be more comprehensive for daytime hours. For those residents with difficult to manage behaviour records need to include the likely triggers and type of behaviour displayed and staff instructions on how to deal with it to diffuse the situation as efficiently as possible. 2. OP15 16(2)i The home must ensure that all meals are served at an acceptable temperature. The written policy concerning DS0000024886.V315560.R01.S.doc Timescale for action 30/11/06 20/10/06 3. OP18 13(6) 30/11/06 Page 27 Selly Park Care Centre Version 5.2 adult abuse must be amended to include that the APT (adult protection team) of Adults and Communities Directorate are informed and any investigations carried out by the home must be as a result of instructions from APT. 4. OP28 18(1) The Organisation must ensure that the plans for the care staff to work towards the NVQ Level 2 qualification in care are completed. N.B. The home has commenced working towards this. 5. OP30 18(1) Staff must receive mandatory training by an accredited trainer for Health and Safety, Moving and Handling, Food Hygiene and Fire Safety. N.B. the home has commenced working towards this. 6. OP33 24(2) The home must develop a report that captures the audits carried out that includes any shortfalls and how they will be addressed including timescales. 30/11/06 31/12/06 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Selly Park Care Centre DS0000024886.V315560.R01.S.doc Version 5.2 Page 28 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.V315560.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!