CARE HOMES FOR OLDER PEOPLE
Shirwin Court 46 Poplar Avenue Edgbaston Birmingham West Midlands B17 8ES Lead Inspector
Jill Brown Unannounced Inspection 21st September 2006 09:00 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 Shirwin Court DS0000017022.V312690.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. Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Shirwin Court Address 46 Poplar Avenue Edgbaston Birmingham West Midlands B17 8ES 0121 420 2398 0121 686 3727 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) Mr Rahmatullah Hissaund Mrs Bibi Hissaund Mr Rahmatullah Hissaund Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The home is able to accommodate ten people by reason of old age of which eight may have mild Dementia. No residents with Dementia are to be admitted to the second floor accommodation. 23rd November 2005 Date of last inspection Brief Description of the Service: Shirwin Court is a privately owned double fronted property that has three floors. The home offers accommodation for 10 older people. The home is situated in Edgbaston close to the Hagley road. From there is public transport available to the centre of Birmingham. Shops and other amenities are available within walking distance to Bearwood shopping area. The home has 6 single and 2 double bedrooms that are located on all three floors. There are stair lifts between each floor. The top flight of stairs is steep and narrow and can only be negotiated by mobile residents. Communal toilet and bathing facilities are available on the ground and first floors. The second floor bedrooms have toilets but the en suite showers are not useable as they cannot be restricted to 43 degrees Centigrade. One of the bathrooms has an in-bath lift for assisted bathing. Not all toilets are large enough for staff to offer assistance. The home has a large well-furnished lounge that overlooks a pleasant garden with shrubs, patio and garden furniture. The separate dining room is used by residents for activities as well as for meals. The home has a ramp and handrails to the front door. Parking is only available on the road. The home currently charges between £314.00-£346.00 per week. Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced key inspection took place on a day in September for about 6 hours. During the inspection three residents’ care files were looked at and two staff files; four residents were spoken to. Maintenance and service records were looked at for the building services of gas, electric, fire and lifting equipment and a tour of the building and garden was undertaken. The inspection visit took place following Concerns being raised by a member of the public. This concern was about a resident who managed to get out of the home without the staff being aware. The inspector looked at this issue in particular and a number of requirements were made about it. Information was also collected together from any contacts from the home and about the home since the last inspection. What the service does well:
The home has a system of collecting information that points to areas of dependency and risk. They collect good information on a resident’s history about their cultural, religious and ethnic background and this can help in making care plans more individual to the resident. Care plans were often detailed and on one care plan seen had good details about health conditions and communication. Residents spoken to were very happy with the care they received in the home. Residents looked well and had their personal hygiene needs were met. Male residents were shaved and a number of female residents were wearing jewellery and had their nails painted or hair done if they wanted. The home keeps good records about residents being assisted to bathe. The inspector received a written compliment prior to the inspection about the good care given to a resident. A relative spoke about the good care provided by the home and he was pleased about the decision to move their relative there. Observations of the relationships seen on the day seen between the owners and the residents was good with a number of residents discussing the recent win by the local football team. The home itself was of a homely appearance and was odour free. There were good records of the maintenance and servicing of the building for electric and gas safety and so on. There was evidence of residents’ personal belongings in their rooms and the bedding and mattresses looked at were of a reasonable quality and were serviceable. Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 6 Residents spoken to said that they were happy with the food. One resident spoke of the special arrangements the manager went to provide different types of fish for them and another resident has soup everyday, as they prefer it that way. The home has 65 staff that have training to NVQ 2 in care or above and this is commendable. What has improved since the last inspection? What they could do better:
The assessments were not in place for all residents before admission and did not always have enough information on residents’ behaviours. Although contracts were on file one contract details were not completed and this means that not all residents have the information about which room they are contracted for, or the cost. Details on how personal hygiene needs are to be met could be improved so that residents that can do some of these tasks, like washing their face, are encouraged to remain doing so. Plans were needed for residents that cannot join group activities and better records were needed of activities that these residents have enjoyed. Records of the food residents have eaten needed to be improved. Daily records were poor and on a number of occasions were not a true record of events. The home were not keeping accident records appropriately and not informing the Commission of events that it is legally obliged to. Medication administration could be improved to ensure that mistakes are less likely and there is a clear checking process. Whilst the home is homely and the surroundings comfortable there were a number of risks to residents. The home had shown that it was possible for residents to get out without staff being aware. Areas where this is possible is through the laundry, which needs an appropriate lock and the back gate of the garden, which needs an improved locking device. The uneven slabs and steps in the garden area are also hazardous. The home must deal with door locks and exits quickly to ensure another resident does not get out of the home and put themselves at risk. Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 7 Whilst it was exceptional that a resident got out of the home the home’s investigation of the complaint was poor and they did not respond appropriately to the complainant and have taken little action since. The home’s facilities could be improved by the purchase of a sluice washing. The current washing machine lacks a sluice cycle and fails to wash soiled laundry appropriately to alleviate any potential infection. The current call alarm system fails to fully protect residents should they need assistance. The home must consider the purchase of a call system that when activated can only be cancelled in the room or point where it has been activated. The home needs to pay attention to the cleaning of the high ceilings, bath equipment and so on to ensure good infection control. The home must implement the food safety process to ensure that food is within date. A bath hot water restrictor needs to be adjusted to operate at a lower temperature. The staffing levels at the home must not drop below two during the day and the home needs to ensure that staff are not working excessive hours. All new employees must have Criminal Record Bureau check or Protection of Vulnerable Adult check before starting work. Staff training whilst generally in place has a gap on moving and handling and this must be put in place without delay. The management of the home was not responding to the changing needs of residents, they did not keep a record of residents views and nor check that the way the home works gives a quality service to the residents. This lack of practice meant some areas of resident needs were not being responded to or fully met. 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.
Shirwin Court DS0000017022.V312690.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 Shirwin Court DS0000017022.V312690.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home has a system to collect good information this is not always collected before a resident’s admission and this could lead to a resident’s needs not being met. Residents or their representatives are not assured formally that the home can meet their needs and contracts are not individual to residents in all cases. EVIDENCE: The home had rewritten the Statement of Purpose to take into account a variation to the conditions of registration. This allows the home to take a number of residents with mild dementia. The home has a contract with residents. A number of these are three way contracts with Social Care and Health. On one file the contract did not have the details for the particular resident completed.
Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 10 The home uses a standard group of assessments in a book format. This gives information when completed on levels of risk and dependency and covers such areas as Communication, Mobility, Mental and Physical Health. Three resident care records were looked at during the inspection. A resident had respite at the home previously and did not have a reassessment by the home before being admitted again although was assessed 7 days later. The social worker gave some information on the circumstances of admission and the resident’s mental state. The home’s assessment format did not prompt detailed information on resident’s behaviour. Another resident had very poor information on admission. The third care record was of a resident that had been at the home for some time. The home’s assessments are reviewed on a monthly basis and the outcome of this should decide whether the plan is still appropriate and prompt any changes needed to the care plan. The home records residents’ ethnic background, communication needs and religion and this information helps to make care plans sensitive to the individual. The home does not inform the resident or the representative in writing that they can meet the needs of the resident. Shirwin Court DS0000017022.V312690.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst personal and health care is given to a reasonable standard poor daily records and injury recording can mean that residents are potentially at risk. Arrangements for recording residents’ medication lacked clarity to pick up errors and could place residents health at risk. EVIDENCE: Care plans were often detailed and contained information on how needs identified should be met for example one resident had plans on Communication, medication administration, diabetes, mobility with a stick and bathing and washing. The communication information was good in that the resident had some hearing difficulties and repetitive speech due to dementia and it stated ‘repetitive be patient, speak slowly can communicate.’ The details on personal hygiene could be improved to detail the parts of this task the residents can do for themselves. Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 12 Daily records showed that when health issues were raised residents were referred to the GP or to other health professionals such as opticians and chiropodists and so on. The inspector found in two instances that the daily records did not reflect the events of the day and this is concerning. The home was not recording all injuries that occurred in the accident book and were not informing the Commission of these injuries. This does not ensure there is oversight of how accidents happen, when and where. It does not ensure that poor moving and handling techniques can be spotted. Care plans did not always respond to resident’s changing needs. Residents were well dressed and had their personal hygiene needs attended to. All the men were appropriately shaved and women had jewellery and their nails painted if they wished. The home keeps a separate record of baths offered and taken and this is good practice. The medication administration records (MAR) were handwritten and were not checked by another person. The manager stated that the Pharmacy had had a problem printing the MAR on this occasion. As a result one medication had been missed off the MAR chart and the home could not show by records that this had been given as the prescription stated. The home kept copies of prescriptions but these were not kept with and opposite the individual MAR that they were about to give another check that the medication is correct. There were no gaps of signatures on medication being administered. However one eye drops medication was still being shown on the MAR after it had been discontinued. One pain relief medication was being given twice a day as a therapeutic dose in the monitored dose cassette but could be given four times a day and a separate stock of medication was kept for this. There was no accurate count of this medication and the home must devise a system that ensures that these medications are auditable. The home stated that no resident is prescribed a controlled drug. Residents that share rooms have screening available if needed. Observations tended to confirm that residents were spoken to appropriately by staff. Residents spoken to said that the staff were good. One resident said that he particularly liked one member of staff ‘ because she jokes and talks with you.’ One resident with communication difficulties because of memory impairment indicated that everything was fine by saying ‘yes home’ and singing. The inspector observed the manager talking to the men in the home about the local football matches and the plans to watch another game. The Commission received a compliment about the care given to a resident in the home prior to her death. Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 13 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, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for social activities fails to include how all residents needs are met including those unable to make choices. The arrangements for visitors were good and enabling to all parties concerned. Residents enjoyed their meals but the home failed to keep good records to ensure that all residents are well nourished. EVIDENCE: Recently daily records suggested that a number of residents were spending their time watching the television as their main activity. The more able residents were able to determine what they wanted to do and spent time either in their room with crosswords, artwork and so on or joined with the other residents. The activity records showed that in the last four weeks that residents had enjoyed another resident’s birthday party. They had exercise sessions; a group discussion and two residents went out. The day of the inspection a group of residents spent the afternoon watching a film whilst in the other lounge one resident was reading; other residents had the TV on but were not watching it. Plans are needed for residents that are unable to motivate activities for themselves.
Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 14 The compliment received suggested that relatives were able to visit when they wanted. A relative spoken to said that he was able to pop in when he wanted. He said that he tried several homes before he found this one and was very pleased with the service they offered. A resident said that the relatives of a resident no longer at the home continued to visit and they enjoyed this. Residents are allowed to go to their rooms they wish. One resident said that they get up early in the morning as early as 5 am. They have a bit of breakfast with the night staff and then have another breakfast with the other residents. The home provided food that residents spoken to enjoyed. One resident said that he likes fish because that is good for his digestion he said the home provided this he has mackerel, herring salmon, cod and so on. He says he has only to ask for something and it is provided for him. Another resident has soup provided as that is their preferred types of meal. Menus do not show all the choices offered. Daily records do not show what and how much residents have eaten. Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 15 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, 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home did not show that complaints were dealt with seriously, investigated thoroughly and actions taken to improve. This impacts on the ability of the home to keep residents safe. EVIDENCE: The home received a complaint from a member of public following a resident leaving the building unseen. This incident was not managed well, and the complaint was poorly handled, with inconsistent information given by the home. The home did not follow its own complaints procedure. A number of requirements are made as a result of this complaint. The home has an adult protection procedure however there is no information to suggest that staff have had training in adult protection. This is necessary to show that staff can recognise abuse and are working within the guidelines of the General Social Care Councils Code of Practice. The home has inventories of residents’ belongings and assist residents with money management where necessary and this is recorded. Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 16 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, 25, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst the environment was homely and odour free, issues of poor infection control and safety especially in the garden area prevented the garden from being as risk free as residents need or would wish. EVIDENCE: The tour of building showed that the home had areas that could be improved. The home was generally odour free. The garden can be accessed by the patio door in the lounge and the laundry. There is an unlocked garden gate to the side of the building, which residents can get out of and this does not provide a secure garden area. Several of the paving slabs are cracked and provide an uneven surface for residents walking in the garden. The garden is terraced and the existing steps Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 17 are unsafe for residents to use and large plant pots partly sectioned these off from the patio. The home on the ground floor had two toilets designated male and female with appropriate signs. The home has call alarms in residents’ bedrooms but these do not need the staff member to go into the bedroom to cancel them. The hot water restrictor did not appear to work on the communal assisted bath. The home had by the bed lighting and lighting over mirrors and this was working in rooms where this was tried. All the radiators looked at were covered to prevent residents getting burns. The main reception, stairs and corridor carpet needed a deep clean and the higher reaches of the ceilings had cobwebs. The in bath lift on the bathroom on the first floor had some soapy deposits. The bath down stairs had a bath mat that also needed cleaning. A resident’s bedroom floor showed sign of a build up of fluff and required vacuuming. A mop kept in the bathroom was stored inappropriately. The home did not have a sluice washing machine available for residents that were incontinent. A toilet frame had some signs of rusting. These lacks mean that good infection control practices were not being maintained. The bed linen and mattresses looked at were serviceable. Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 18 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, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home was not ensuring that there was enough staff on duty and that staff had the checks required and this could put residents at risk. The training that staff had was improving. EVIDENCE: The home provided four weeks worth of rota. Following the inspection information came to light that a number of staff may be working in more than one home and working excessive hours. Concern was raised by the complainant that only one member of staff was on duty on one evening. On the day of the inspection one person was on duty whilst the manager went to get a prescription a third member of staff arrived later. The rotas are not organised in a way to reflect differing start times. The home has 65 of its staff trained to at least the equivalent of NVQ 2 in care. The home had evidence that staff appointed had the relevant checks but necessarily before starting work at the home. The home ensured new staff had an induction. Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 19 The home supplied a matrix of staff training that showed when staff had undertaken mandatory training. This showed that in most areas the staff received training in a timely way. Moving and handling update training and adult protection is required. The home stated that the staff were to undertake dementia awareness session this month. Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 20 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, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home were not developing the home’s systems to meet increased expectations of residents and regulators. This means that the home are not identifying areas where they need to improve and this could fail residents safety and wellbeing was being fully promoted and protected. EVIDENCE: The owners that manage the home have said they have completed the Registered Managers Awards and copies of these certificates must be sent to the Commission. The home did not have audit tools to ensure that the service stayed at a consistent good quality and did not have a formal quality assurance system. As a small home they have not had residents meetings but say they discuss
Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 21 thing with residents. They must ensure they have ways of collecting together residents views so that they can show how the home is improving to the service it provides. The home manages a float of money for a number of residents given to them by relatives and this is recorded. The record showed that the home ensured that residents hairdressing, chiropody, clothing and for some cigarettes were bought from this money. Receipts matched the spending on accounts looked at. The amount of money held for residents matched the records and a sample of the accounting tallied. The home had copies of maintenance documents such as checks on Gas, Water and Electric safety. The Food Safety Department had been inspected the home in January 2006 and recommended different coloured chopping boards and this remained outstanding. It was recommended that the home use the specially produced Food Safety pack as a tool to ensure good food practices. This pack had not been used by the time of the inspection. The kitchen fridge had eggs in it that were out of date and the fridge seal had split and needed replacing. The home was taking appropriate actions to ensure that the home was safe if there happened to be a fire. There were records of fire drills, in house training since the last formal training in November 2005, alarm and emergency lighting tests and a specialist company had maintained the fire extinguishers. The home was not informing the Commission of events that affect the well being of residents. Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 22 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 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 X X 2 X X 2 2 STAFFING Standard No Score 27 1 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 2 Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5(1)(b)(c) Requirement The home must ensure that each resident has terms and conditions of the accommodation including the amount the fees and a standard form of contract. All residents must have an assessment prior to admission into the home. The home must send a letter to the resident or their representative that the home is able to meet the residents needs if following their assessment they are willing to accept the resident. Care plans on personal hygiene must detail how care is to be given and what the resident can do theirself. Care plans must be updated when it is identified that a resident’s need has changed. All injuries must be recorded in the home’s accident book and daily records. The home’s daily records must accurately reflect events that
DS0000017022.V312690.R01.S.doc Timescale for action 31/10/06 2 OP3 14(1)(a) (d) 31/10/06 3 OP7 15(1)(2) (b) 31/10/06 4 5 OP8 OP8 Sch4 (12)(a)(c) Sch3 (3)(j) 31/10/06 31/10/06 Shirwin Court Version 5.2 Page 24 6 OP9 13(2) 7 OP9 13(2) 8 OP12 16(2)(n) 9 OP15 Sch4(13) 10 OP16 22 happened on that day for the resident. All hand written MAR must be checked by another person and must have two signatures confirming this. The home must ensure that the system of medication allows a quick method of auditing. (Outstanding since 31/12/06) All residents that are unable to motivate activities for themselves must have an activities plan and the activities they have enjoyed recorded in their daily record. The home must ensure there is a comprehensive record of the type and amount of food a resident eats. The home must investigate, document and respond to any complaint as stated in the homes complaint procedure. The home must implement any action points that arise as investigating the complaint. All staff must attend adult protection awareness training. The gate at the side of the garden must have a lock to prevent residents that are at risk from leaving the premises unseen. The laundry door must have a numbered lock to ensure the safety of residents. The paving slabs must be re-lain to provide a level surface. The garden steps must be made safe. The hot water outlet on the communal bath on the first floor must be restricted to 43 degrees Centigrade.
DS0000017022.V312690.R01.S.doc 31/10/06 31/10/06 30/11/06 30/11/06 31/10/06 11 12 OP18 OP19 13(6) 13(4)(c) 31/01/07 31/10/06 13 OP19 13(4)(c) 30/11/06 14 OP25 13(4)(c) 31/10/06 Shirwin Court Version 5.2 Page 25 15 OP26 13(3) Mops must be appropriately stored and not left in water. The home must ensure that cobwebs are removed from the high ceilings. Bath aids such as bath mats and bath lifts must be thoroughly cleaned after each use. Toilet frames must be inspected for rust and remedial action taken. The registered person must be mindful of the need to provide a sluice washing machine to meet the needs of the residents. (This remained outstanding since 30/06/06) The home must have at least two people on duty and in the home between the hours of 8am and 9pm. The rota must be a true record of the hours that staff do. All staff must declare their places of work and any staff undertaking more than 48 hours in total must sign an agreement to work these hours. Any staff that works over 48 hours must have a risk assessment to show that they remain competent and willing to do these hours and this must be regularly reviewed. All staff must have a Criminal Records Bureau check before employment is commenced at the home. (Outstanding since 31/01/06) All staff must have an up to date moving and handling update training.
DS0000017022.V312690.R01.S.doc 31/10/06 16 OP26 23(2)(k) 31/12/06 17 OP27 18(1)(a) 31/10/06 18 OP29 19 31/10/06 19 OP30 13(5) 30/11/06 Shirwin Court Version 5.2 Page 26 20 OP31 10(2) 21 OP33 24 22 OP38 37 23 OP38 13(3) Copies of the manager’s certificates for the Registered Managers Award must be submitted to the Commission. The Registered Person must ensure that systems are in place to review and improve the service provided. (Outstanding since 31/08/06 and 31/03/06) The home must inform the Commission of anything that affects the wellbeing of residents including; Bruising, injuries, falls, pressure areas and residents leaving the building without knowledge. The home must ensure that they have an adequate food risk assessment that ensures that: Food remains in date Equipment is serviceable and Required temperatures are recorded. 30/11/06 31/12/06 31/10/06 31/10/06 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 OP22 Good Practice Recommendations It is recommended that the photocopy of the prescription be kept next to the medication administration record that it relates as an added check. It is strongly recommended that the call system be replaced with one that has to be cancelled within the residents’ bedrooms. Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 27 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 Shirwin Court DS0000017022.V312690.R01.S.doc Version 5.2 Page 28 - 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!
