Inspection on 15/02/07 for Stennards (Fb)

This inspection was carried out on 15th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Stennards (Fb) 18/01/06

Stennards (Fb) 16/08/05

Stennards (Fb) 22/02/05

Stennards (Fb) 21/09/04

Stennards (Fb) 20/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Stennards (Fb) 123 Frankley Beeches Road Northfield Birmingham West Midlands B31 5LN Lead Inspector Brenda O’Neill Key Unannounced Inspection 15th February 2007 09:15 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 Stennards (Fb) DS0000016785.V327142.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. Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stennards (Fb) Address 123 Frankley Beeches Road Northfield Birmingham West Midlands B31 5LN 0121 477 5573 0121 605 7799 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 Peter David Lee-Harris Mrs Dawn Lee-Harris Miss Rhonda Ann Macey Care Home 18 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (18) of places Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate three named service users who are elderly and have dementia DE (E). 18th January 2006 Date of last inspection Brief Description of the Service: Stennards Frankley Beeches Road is located along Frankley Beeches Road, a short distance from shops and other local amenities in the Northfield area. The home is registered to provide care and accommodation for eighteen older people. The home provides residents with the opportunity to participate in communal activities and to go out for daytime activities at a church centre. The home is a large detached house with ten single bedrooms eight of which have en suite facilities and four double bedrooms all of which have en-suite facilities. The remaining single rooms have wash hand basins. Off road parking is available at the front of the building. To the rear of the house is a large wellmaintained garden. This has many attractive features such as a fountain and there are several secluded areas where people can sit and talk privately with friends or visitors. The garden is laid out so that it is possible to walk round the back of the building on paving passing through various parts of the garden. There is a large sitting room, a separate dining room and two conservatory areas, one of which joins the lounge area to the rear bedroom corridor and the other leads off the dining room. There are good views of the garden from both conservatories. The home does have an entrance at the front of the building for people with mobility difficulties. There are two stair lifts in the home. The fees at the home range from £313.86 to £345.00 per week plus £15.00 top up per week. Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was carried out by one inspector over one day in February 2007. During the course of the inspection a tour of the premises was carried out, one staff and three resident files were sampled as well as other care and health and safety documentation. The inspector spoke with the manager, the proprietors and four of the seventeen residents. Prior to the inspection the manager had completed and returned to the Commission a pre inspection questionnaire which gave additional information about the home. The home had not had any complaints lodged with them since the last inspection and none had been raised with the Commission. What the service does well: This home consistently offers a good level of service to the residents and the requirements made at inspections are minimal. Good pre admission assessment procedures were in place that ensured staff knew and could meet the needs of the residents prior to admission. There was very comprehensive documentation that staff were able to recognise the health care needs of the residents and then would follow these up and ensure they were monitored. The system in place for administering medication was well managed and ensured the residents received their medication as prescribed. There were no rigid rules or routines in the home and residents were encouraged to exercise choice and control over their lives. There were activities on offer that appeared to meet with the needs of the residents. The menus at the home were varied and nutritious and residents were offered choices at all meals. Staff turnover at the home was very low which was very good for the continuity of care of the residents. Relationships between the staff and the residents were very good and the residents were clearly comfortable in the presence of the staff. Staff received a good range of training on an ongoing basis ensuring they had all the required skills and knowledge to be able to care for the residents. The home was well managed and there were good relationships evident between the manager, residents and staff. The proprietors continued to visit Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 6 the home virtually every day to offer their support and also knew the residents well. The home offered the residents a good standard of accommodation that was homely and well maintained. Health and safety at the home were very well managed. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 7 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 Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 8 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): 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents were able to visit the home prior to admission to assess the quality, facilities and suitability of the home. The assessment procedures in the home were good and ensured staff knew the needs of the residents prior to admission. EVIDENCE: The files for three residents admitted to the home since the last inspection were sampled. All the files included copies of the social workers pre admission assessments and an initial care plan drawn up by them. The staff at the home also undertook their own assessments on the preview visit to the home. All the files sampled included details of these assessments and comments about how the individuals’ day at the home had gone and if the home could meet their needs. Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans and risk assessments in place were comprehensive and identified how the residents needs were to be met and how any risks were to be minimised. The medication system was well managed and ensured residents were safeguarded. EVIDENCE: All the files sampled included comprehensive information about the individual residents and their needs. On the day of admission the manager wrote an initial overview of the resident their needs and the reason for admission to the home for staff to read. The manager then completed a booklet entitled ‘Good care planning assessment’ these included a personal profile of the individual, how things can be improved, details of preferred activities, and numerous assessments for such things as mental health, tissue viability and nutrition. There was some very good detail in the booklets of the specific needs of the residents, for example, of how an individual’s short term memory affected her Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 10 and for another resident detail of an ongoing eating disorder and how staff were to monitor this. All files also included ‘a day in life of’ which gave an overview of what the individuals’ needs were throughout the day and night and how staff were to meet them. These were well detailed and some improvements had been made since the last inspection to ensure they included how staff were to meet any identified needs. They included such things as likes, dislikes and preferences, what the residents were able to do for themselves and also where they were able to make choices. All the files sampled also included manual handling assessments that detailed how residents were to be assisted should they fall and they were not injured. As stated there were several other risk assessments in the booklets. Any specific risks were detailed in the residents’ profiles, for example, there was very good detail of how staff were to manage a residents behaviour when they were being verbally challenging. It was strongly recommended that the manager ensured that staff signed to say they had read and understood the assessment booklets as there was a lot of information in these that staff needed to be aware of. The format being used for the daily records had improved and gave the staff more space to write about the well being of the residents. The manager had also included a separate report sheet for additional information. Staff needed to ensure that the daily records, the report sheets and health care records were all cross referenced to each other to ensure staff knew where all the relevant information was. The was very comprehensive documentation of the residents’ health care needs being identified, followed up and monitored. All appointments at hospitals and visits by health care professionals to the home were clearly detailed and the outcomes of the visits very well detailed. There was evidence that ongoing health care issues were monitored, for example, diabetes. Where it had been identified that residents were at risk of losing weight this was detailed and monitoring records were kept at the required intervals. The manager had recently changed the pharmacist she was using to dispense the residents’ medication as she was not happy with the service being provided. Medication continued to be administered via a monitored dosage system but was in weekly Nomad packs instead of 28 day blister packs. The manager stated the system was going well and was easy to manage. Only the manager and staff who had undertaken accredited training were administering medication. Some of the records were sampled, all medication was being acknowledged as received into the home, any balances held in the home at the end of the 28 day cycle were being carried forward and all medication was being signed for when administered. All medicines that were audited were found to be correct. Only one minor issue arose. One resident had been Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 11 prescribed some medication that she was to take at mid day and then again later if required. The manager needed to ensure that there was written guidance for staff to follow as to when the second dose should be administered. The inspector was informed there was no controlled medication being administered in the home at the time of the inspection. The privacy and dignity of the residents was well maintained. Residents were able to spend time in their rooms if they wished without being disturbed. All bedroom doors could be locked and lockable facilities were available if required. There was adequate screening available for the double bedrooms if required. Medical consultations took place in the privacy of the resident’s rooms and there were quiet areas where visitors could be received. Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 12 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. There were no rigid rules or routines in the home and residents were encouraged to exercise choice and control over their lives. There were activities on offer that appeared to meet with the needs of the residents. The meals in the home were good with choices available. EVIDENCE: There did not appear to be any rigid rules or routine in the home. It was evident throughout the course of the inspection that staff had very good relationships with the residents. Residents were observed to spend time quietly in their rooms, chatting in small groups, wandering around, reading and taking part in an organised activity during the afternoon. The daily records on the files sampled evidenced some activities, for example, listening to music, going shopping, chatting to other residents, watching television, sing song and hairdressing. There were also separate activity sheets that documented when residents took part in organised activities including cards, bingo, roulette and football cards. Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 13 Several of the residents attended a day centre once a week where they met with the residents from other homes owned by the same proprietors. Three of the residents were able to use public transport and all were registered with ring and ride. The manager stated none of the residents chose to go out to church but there was a visiting minister every Sunday. There were no restrictions on visitors to the home within reasonable waking hours. Residents were free to go out with friends and relatives as they wished. Copies of the menus for the home were sent to the Commission with the pre inspection questionnaire. These showed that there was a good variety of food offered to the residents and there were choices available at all meals. The menus were available for the residents on the dining room tables. Food records were being kept and these showed that residents received the foods detailed on the menus. The inspector was at the home during lunchtime and residents appeared to enjoy their food in a pleasant environment. Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 14 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 excellent. This judgement has been made using available evidence including a visit to this service. There is an appropriate complaints procedure at the home that is issued to all residents. The policies and procedures on site and the training staff had received ensured staff were aware of the importance of protecting residents from abuse. EVIDENCE: There was an appropriate complaints procedure on display in the home and a copy of this was issued to all the residents in the welcome pack. No complaints had been lodged with the home and none had been received by the CSCI. The residents at the home were comfortable in the presence of the manager, staff and the proprietors and very good relation ships were evident. This would give residents the confidence to raise any issues they may have. The proprietor stated that if any issues did arise with residents or their relatives they would address them very quickly to ensure they did not get out of hand. Staff had received training in the protection of vulnerable adults and this was regularly updated. The policies and procedures in relation to adult protection, whistle blowing managing aggression and physical intervention were not viewed at this inspection. They had been seen previously and the inspector was informed no changes had been made. Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 15 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, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers residents a safe, well maintained, comfortable and homely place to live. EVIDENCE: There had been no changes to the layout of the home and it was comfortable, safe and well maintained. The proprietors of the home were very frequent visitors and were very quick to address any issues raised. No requirements were made in relation to the environment following the last inspection. Several improvements had been made at the home since the last inspection: the kitchen had been totally refurbished with new units, flooring and tiling, new windows had been fitted in the conservatory, some bedrooms and corridors had been recarpeted, several areas had been repainted, a new large plasma Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 16 television had been purchased, new crockery and cutlery had been purchased and some new bed linen. There were a variety of communal areas in the home which include a smoking area for the residents. All the areas were nicely decorated and all furniture and fittings were domestic in character and varied throughout. The garden area was very pleasant, well maintained and was accessible to the residents with furniture available for their use. There were adequate toilets and bathrooms throughout the home. Several of the bedrooms had en-suite facilities of toilet and wash hand basin. There were three bathrooms and one fully assisted shower room in the home. One of the bathrooms had a motorised bath seat for ease of access for the residents. The manager stated that the majority of the residents preferred to have a shower rather than a bath. The aids and adaptations throughout the home appeared to meet the needs of the residents and included a floor level shower, hand and grab rails, emergency call system and stair lifts. The emergency call system had been changed since the last inspection so that staff had to attend the point of the call to cancel it. Bedrooms sampled varied in size, were comfortable and adequately furnished and decorated. All were appropriately personalised to the occupants choosing. One resident was seen ‘pottering’ around in her room and although it was evident she had a degree of confusion she was clearly very happy with her room. All bedrooms were lockable if residents wished to have a key. The home was warm, well lit and appropriately ventilated. All radiators had been covered and thermostatic mixer valves had been fitted to the hot water outlets to ensure residents would not scald themselves. On the day of the inspection the home was clean and odour free. The laundry was appropriately located and equipped with washing machines, tumble driers and a sluice facility. As at the last inspection it was recommended that when the washing machine is replaced one with a sluice facility is purchased. Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 17 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 excellent. This judgement has been made using available evidence including a visit to this service. The appropriate staffing levels were being maintained by a well trained, longstanding staff team who were able to meet the needs of the residents. Recruitment procedures were robust and safeguarded the residents. EVIDENCE: Staff turnover at this home is very low which is very good for the continuity of care of the residents. Only one new staff member had been appointed since the last inspection. Staffing levels were being maintained at three care staff throughout the waking day (one of whom was a senior) and two staff throughout the night. The manager’s hours were supernumerary to the care rota. There was no cook employed at the home and this was done by staff on duty however domestic staff were employed. The proprietors also attended the home virtually every day. Relationships between the residents, staff, manager and proprietors were very good. The proprietors were regular visitors and appeared to know all the residents very well. The recruitment records for the one new employee were seen. There was a completed application form, a full C.V., three written references and proof of Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 18 I.D. the CRB number was included on the file but the CRB was being kept by the proprietor to ensure confidentiality. The proprietor was reminded that CRBs should be available for inspection. She did offer to fetch the document for the inspector but as there have not been issues with recruitment at this home in the past this was not felt to be necessary. Evidence of the check was faxed to the Commission a little after the inspection. There were very comprehensive induction records for the new employee. The induction was in line with the specifications laid down by Skills for Care and had been signed off over the first nine weeks of employment. There was also evidence that the employee had the required certificated training in relation to food hygiene, fire procedures and infection control undertaken at the home as well as a lot of evidence of previous training. The training records for four other staff were sampled and it was evident that the staff team were well trained on an ongoing basis. There was a yearly training programme in place and all mandatory training was updated including, adult protection, first aid, food hygiene, infection control, manual handling and fire procedures. Staff also received training in other topics such as, risk assessment and death, dying and bereavement, needs of the service user, challenging behaviour and report writing. A little over fifty percent of staff at the home were qualified to NVQ level 2 or above. Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 19 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, 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 ensures the smooth running of the home in a competent manner with regular input from the proprietors. The health and safety of the residents and staff was well managed. EVIDENCE: The manager of the home had worked there for many years and had a lot of experience of caring for elderly people and the running of a residential home. She had completed her registered Manager’s Award but was having difficulty securing funding to complete the required modules of training for the NVQ level 4 in care. She was still pursuing this. The proprietors were regular visitors to the home and offered any necessary support to the manager. Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 20 It was evident throughout the course of the inspection that relationships between the manager, residents and staff were very good. The home had a quality assurance system in place that had been purchased from an outside agency that they were working their way through. This involved auditing all the standards in the quality manual against what was in place at the home and highlighting any short falls. The system involved seeking the views of the residents and any other stakeholders in the home. The proprietor had completed a brief quality review in January 2007 stating what had been achieved in 2006 but there was no development plan in place for 2007. The home needed to have an annual development plan in place based on seeking the views of the residents and taking into account the outcomes of the quality audits with a view to continually improving the service. The manager was handling some of the finances for some of the residents. The records for these were sampled and found to be appropriate. All the balances checked were correct, receipts were available for expenditure, where they were able residents were signing for their own money. The manager and another member of staff were checking the balances on a regular basis. Staff were receiving supervision at regular intervals from the manager. Records of the supervision sessions were seen on the staff files sampled and appropriate topics were being discussed. Health and safety at the home were very well managed. Staff received training in safe working practices. The manager and the proprietors were very proactive in ensuring that the home was a safe place for the residents to live and staff to work. There was evidence on site that all the necessary equipment was regularly serviced. All the in house checks on the fire system were up to date and regular fire drills were carried out. All the requirements made by the fire officer at his most recent visit had been addressed. The fire risk assessment was up to date and had been reviewed. There were no requirements made by the environmental officer at his last visit to the home. Accident and incident recording and reporting were seen to be appropriate. Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 3 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No. 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 OP8 Regulation 12(1)(a) Requirement The manager must ensure that all daily records, additional report sheets and medical records are cross referenced to each other. There must be written protocols in place for any medication that is to be administered on an as required basis. The registered manager must be qualified to NVQ level 4 in care and management or the equivalent. (Previous time scale of 30/06/06 not met.) The home must have in place an annual development plan based on seeking the views of the residents with a view to continuous improvement. Timescale for action 01/04/07 2. OP9 13(2) 14/03/07 3. OP31 9(2)(b)(i) 30/06/07 4. OP33 24(1)(a) (b) 01/04/07 Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 23 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 OP7 OP26 Good Practice Recommendations It is strongly recommended that staff sign to say they have read and understood the assessment booklets for the residents. It is recommended that when the washing machine is replaced one with a sluice cycle is purchased. Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 24 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 Stennards (Fb) DS0000016785.V327142.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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