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Inspection on 05/07/05 for The Firs Nursing Home

Also see our care home review for The Firs Nursing Home for more information

This inspection was carried out on 5th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 21 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home meets regularly with residents to discuss important issues such as choices in the home and potential and real risks. The home has risk assessments to help identify the residents changing mental health, this enables the resident to receive early support from community mental health teams.

What has improved since the last inspection?

The home has improved the information available to prospective residents in respect of the facilities, service and resources at the home. A pre-admission assessment form has been devised to assist the home to gather appropriate information prior to agreeing new admissions to the home. The home has introduced communal hot and cold drink making facilities. The safe management of medicines in the home has improved. Fire safety has been improved including confirmation of maintenance and service of the fire system.

What the care home could do better:

The home must plan the care of residents based upon a thorough assessment of need, including good management plans where risks are identified inconsultation with residents. This must include how the lifestyles of residents such as leisure and occupation will be supported. A review of polices, practice and staff training in respect of protecting vulnerable residents is needed to ensure and promote their safety. The home needs to develop and implement a programme of refurbishment in residents` rooms and in some communal areas. Control of infection management must be improved and based upon a robust risk assessment process. Staffing levels, supervision, training and performance must be maintained and improved to adequately support residents. The home must develop a system of quality assurance to assist them with the process of self-monitoring and continuous improvement.

CARE HOME ADULTS 18-65 The Firs Nursing Home 745 Alcester Road South Kings Heath Birmingham B14 5EY Lead Inspector Sean Devine Unannounced 5 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Firs Nursing Home Address 745 Alcester Road South Kings Heath Birmingham B14 5EY 0121 430 3990 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Janet Murrell Rosemary Claye Care Home with Nursing 25 Category(ies) of Mental Disorder (25) registration, with number of places The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can care for 13 (thirteen) named service users over 65 years of age which is outside the category of registration. 2. The home must ensure that the changing needs of the older service users can be met and that these care needs remain under regular review. 3. The home must only provide a service to other service users aged 40 years or over. Date of last inspection 25 January 2005 Brief Description of the Service: The Firs is a care home, which provides nursing care and support to 25 adults with enduring mental ill health. The home is located close to the Maypole area of Kings Heath. It is close to local shops, post office, banks, and leisure facilities. It is located on a major trunk road into Birmingham, which also has good motorway connections. A regular bus service passes the home enabling easy access to Kings Heath and the city centre. The home was first registered in 1987. The home consists of the original house, and a newer extension. The home offers accommodation over three floors. The home has both single and shared bedrooms. No rooms have ensuite facilities. The home has a passenger lift enabling access to all floors. The home has an attractive rear garden. The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted on an unannounced basis by one regulation inspector over a period of one day. The inspector had the opportunity to meet with many residents and some relatives, some staff were observed in the course of their duties. Records pertaining to care provision and health and safety in the home were seen. A conducted tour of the premises was undertaken. The inspector is concerned that many of the requirements from the last inspection remain outstanding, this includes concerns in respect of staff training and supervision and the homes ability to adequately protect the residents from possible risks of abuse. What the service does well: What has improved since the last inspection? What they could do better: The home must plan the care of residents based upon a thorough assessment of need, including good management plans where risks are identified in The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 6 consultation with residents. This must include how the lifestyles of residents such as leisure and occupation will be supported. A review of polices, practice and staff training in respect of protecting vulnerable residents is needed to ensure and promote their safety. The home needs to develop and implement a programme of refurbishment in residents’ rooms and in some communal areas. Control of infection management must be improved and based upon a robust risk assessment process. Staffing levels, supervision, training and performance must be maintained and improved to adequately support residents. The home must develop a system of quality assurance to assist them with the process of self-monitoring and continuous improvement. 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 Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 Essential information is available for residents and their representatives to make an informed choice as to whether the home could meet their needs. The home does not fully assess residents, which means they may not receive the care they need. EVIDENCE: The home has further developed the statement of purpose, which fully describes the homes aims and objectives, the services and facilities available at the home. The home ensures that detailed information is gathered prior to admitting residents to the home, this includes reports from social workers. The home has developed its own pre-admission assessment form, which will be used to assist in the assessment of future admissions. However the form was not available at the time of inspection in respect of the resident most recently admitted to the home. The home does not provide care staff with training to support the specific mental health needs of residents. Staffing levels are adequate to meet residents’ needs. The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 and 9 Residents’ risks and care needs and their ability to care for themselves are not fully assessed and planned for, which means residents do not receive appropriate support and care. EVIDENCE: Written care plans developed from assessments are in place and these plans are reviewed on a monthly basis. However, some sections of the homes assessments are not completed, some are very brief, many do not describe the abilities of the resident and only describe where staff intervention or support is needed. These plans must include what residents can do to meet their own needs. The description of need on some plans is not clear. Some written care plans are risk assessments and some care plans have not been signed or dated. Care plans, which are no longer used, should be removed from the current files of residents to ensure there is no confusion for staff or residents. The home has introduced residents meetings, which are recorded and also questionnaires to help involve residents in making decisions and choices about the home. Residents need to be involved throughout the assessment, care planning and review processes where they wish. The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 10 Risk assessments are in place and some where possible have been completed with residents. Not all risk assessments are evaluated on a monthly basis and some are completed on differing formats, which is potentially confusing for staff. The home has not developed risk assessments for areas of concern recently identified on a Regulation 37 Notification. Sampled residents files’ included a risk management plan for possible mental health relapse and associated triggers and action plans. Risk assessments; in respect of nutrition, mobility and skin care have not been completed for some residents who would benefit from these assessments. The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,14,15 and 16. Residents are not supported to identify their potential in respect of life long learning, leisure pursuits and relationships, information and access are not fully sought and opportunities are limited. EVIDENCE: Sampled residents files include some details of a life history, however these were seen to be brief and appeared to have little input from residents and their relatives. Residents assessments in respect of their education / occupational needs and relationships are assessed, however access and information about education and occupation was not seen to be available in the home and residents did not confirm they have such choices. Details of relatives and significant persons in the lives of residents are recorded, however how these people are involved in the lives of residents are not fully assessed and planned for. Sampled residents files did not include an assessment with associated care plans detailing the leisure needs of residents. To support some residents in respect of daily routines and any limitations the home has developed one to one key-worker sessions for some residents. This The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 12 practice should be extended to all residents. All residents have their own key for their rooms and with exception of areas such as the main kitchen have unlimited access to all parts of the home. The home has introduced refreshments hot and cold (within the dining area), which are available at all times, the manager confirmed that when a risk is present hot water supplies are removed from this area. This practice needs to be identified in a risk assessment. The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 and 20. The health and medical care of residents are met in the home. The specific personal care needs of residents are not fully assessed which impacts on their choices and preferences. Medication practices are not entirely adequate to maintain effective treatment for residents. EVIDENCE: The residents’ ability to maintain their own personal care needs are assessed and planned for by the home. However in part they do not specifically identify what assistance is needed, whether it be for instance with bathing, dressing or grooming. Specific preferences in dress, hairstyles and make-up are not recorded. The home maintains good records of appointments and outcomes with healthcare professionals including social workers, community psychiatric nurses, chiropodists and with specialist care such as hospital dieticians. Medical care needs such as with GP’s is also well recorded. Sampled files included a risk assessment of the residents ability to selfadminister medicine. The home manages and administers all medicines on behalf of the residents. The management of medicines needs to be improved to ensure it is safe. As required medicines must have a protocol for staff to refer to, balances of medicines must be accurate and a policy for homely medicines must be available. The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 14 The home is in the process of changing the dispensing chemist and must amend its medicine policy to reflect any new practices. The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Residents complaints are listened to by the home and actions are taken to resolve areas of concern. Staff training and policies in respect of protecting vulnerable residents from abuse are not adequate and mean residents maybe put at risk. EVIDENCE: The home has a complaint policy, it is available in the home and included within the statement of purpose and residents terms and conditions of residency. A log of complaints detailing concerns, actions and outcomes is available at the home. Staff training in respect of protecting vulnerable adults from abuse has not commenced. The policy to protect vulnerable adults has not been updated to comply with local multi-agency guidelines. The home does manage some money on behalf of residents, at present the manager and owner are in dialogue with Social Care and Health to determine how residents’ allowances and benefits are to be paid. The present system of money being paid into the owners account does not adequately protect residents and must be revised. The home does keep a detailed inventory of all residents’ property and belongings. The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) all standards. The management of infection control does not protect the health and safety of residents and staff in the home. Residents are not fully provided with a comfortable and safe environment to enjoy their lives. EVIDENCE: The home is pleasantly decorated in most areas, most furnishings are of good quality and domestic in style. However the home has not developed a programme of renewal and maintenance as identified at the last inspection. The home has eight shared rooms and nine single rooms, space requirements have not been measured, however there appears to be adequate space for all residents. Residents’ rooms on the ground floor must have net curtains to maintain the residents privacy. Furniture and fittings in residents rooms was found to vary, the home must ensure adequate storage space is available, that all windows are kept clean, comfortable seating is available and that flooring is clean. Facilities in toilets and bathrooms rooms vary and include assisted baths with hoist chairs and showers with grab rails. Toilets are close by all resident accommodation. The home must ensure appropriate hand drying facilities are The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 17 available at all wash hand basins and that residents’ toiletries are returned to their rooms after use, that tablets of soap are not used in toilets unless returned to residents rooms, liquid soap should be available. The home has two large lounges and a smoking room, the lounges are pleasantly decorated and well maintained. Adequate lighting in all lounges must be maintained at all times. The smoking room is of concern, flooring and seating is heavily marked with cigarette burns. The garden areas are accessible with lawn, patio and seating available. This area must be maintained safely at all times, concerns in respect of infection control must be adequately managed through a risk assessment process including specific measures to reduce the risks to resident and public health. The home has sluice rooms, which are in regular use by domestic staff, these must be kept locked at all times. A clinical waste contract is in place, however clinical waste bags must be placed in an appropriate receptacle. The kitchen and laundry areas were generally found to be clean, specific attention is needed on a daily basis to frequently used equipment such as microwaves and drip trays under hobs. The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,36 Residents are not receiving adequate staff support to meet their nursing needs, this means the residents mental health needs are not fully met by the home and they are at risk of relapse and inappropriate care. EVIDENCE: The staffing levels are maintained as two registered mental nurses and three care assistants during all day hours. This is deemed as an adequate amount of staff to meet the care and nursing needs of residents. However, care staff must not be rostered onto domestic duties during the day, adequate domestic support must be provided whilst three care assistants remain available for the support and assistance to residents. It was evident throughout the inspection that nursing staff did not spend allocated periods of time with residents on an uninterrupted basis, many interactions were initiated by residents in search of staff. Some care staff were seen frequently supporting residents in the smoking area. Nursing care of residents other than for medication was limited. The manager confirmed that care staff training in respect of mental health awareness had not been completed as required at the last inspection. Supervision of nursing staff is not frequent and does not include clinical nursing issues and practice. Care staff are supervised more frequently however records are not always available. The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39,42 The management and administration of the home ensures the health and safety of residents and staff alike is positively addressed. The home does not adequately monitor the quality of the service provided and thus does not provide a basis for continual improvement. EVIDENCE: The home does complete residents’ surveys frequently; this includes feedback from residents in respect of facilities, services and activities at the home. The manager has ensured that the regular testing and service of systems and utilities is maintained including; fire systems, staff fire drills and training, gas and electrical safety and the homes emergency call system. The manager must ensure that the maintenance person is competent to undertake portable appliance tests and update the fire risk assessment to include compliance and findings. The accident and incident records are well completed by the home in compliance with relevant legislation, however the commission has not received The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 20 notification of the recorded incidents, and incident logs for residents involved had not been updated. These records are audited six monthly by the manager, the frequency of audit needs to be increased to ensure trends are identified earlier. The manager must ensure that fire doors with hooks to retain them in the open position have the hooks removed, if fire doors need to be held open they should be fitted with devices linked into the fire alarm system. The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 2 x x Standard No 22 23 ENVIRONMENT Score 3 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 3 x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 3 3 3 1 Standard No 11 12 13 14 15 16 17 x 1 x 1 2 2 x Standard No 31 32 33 34 35 36 Score x x 2 x 2 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Firs Nursing Home Score 2 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14(1) Requirement Timescale for action 31/8/05 2. YA3 The home must complete a preadmission assessment of prospective residents and maintain records of the preadmission assessment. 14, Evidence that prospective service 30/9/05 18(1)(a)(c users assessed needs can be met )(i) by the home must be provided. This must include staff competencies in respect of mental health awareness. Previous timescale of 30/6/05 not met, this requirement is carried forward. All assessments of daily living, personal, social and healthcare support for residents must be completed. All assessments must be thoroughly completed and describe the need and abilities of the residents. All care plans must clearly describe the needs of residents and be accuratley completed including signatures and dates. Written care plans where risks 3. YA6 14 30/9/05 4. YA6 15(1), 14(4)(c ) 31/8/05 The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 23 are identified must be written within a risk management framework. Old care plans which are not in current use must be archived. Residents must be invited to take part in the assessment, care plan and review of their care. All residents risk assessments must be evaluated each month. Risk assessments must be completed within a consistant format. Risk assessments must be completed where a risk is identified including risks of being missing from the home. Risk assessments for all residents over 65 years of age and where a need is identified in respect of nutrition, tissue viability and mobility / manual handling must be completed. The educational and occupational 30/9/05 opportunities including access must form part of the residents assessment. A full assessment of residents 30/9/05 leisure activities including pastimes, hobbies and interests must be undertaken. Care plans must then be developed to enable service users to fulfil their pursuits. Previous timescale of 30/6/05 not met, this requirement is carried forward. The home must assess who is important in the lives of residents and develop care plans to encourage and maintain the 5. YA9 13(4) 31/8/05 6. YA12 14(1) 7. YA14 16(2)(m) 8. YA15 16(2)(m) 30/9/05 The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 24 relationship. Previous timescale of 30/6/05 not met, this requirement is carried forward. All residents who have difficulty with routines and who exhibit institutionalisation must have a keyworker to work with, where needed on a one to one basis A protocol/procedure to inform all residents of when the hot drinks facilites are not available due to prevalent risk must be utilised. . Specific information as to how each individual resident needs support in respect of personal care must be completed and a written care plan developed, this must be specific e.g. assistance with washing, grooming, how many staff, what facilities etc. Specifc preferences of residents to reflect their choice and personality must be recorded and planned for, e.g. hairstyles, dress and make-up. The home must record quantities and carry over balances of medication on the MAR chart to enable audit to be completed. The manager must rewrite medicines policies to reflect new practice. Previous timescales of 31/5/05 and 24/1/05 respectively were not met, these requirements are carried forward. The manager must ensure that protocols are in place for administrations of all as required medicine. The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc 9. YA16 12(1), 13(4) 30/9/05 10. YA18 14(1),15( 1) 31/8/05 11. YA20 13(2) 31/8/05 30/9/05 31/8/05 Version 1.40 Page 25 12. YA23 13(6) A policy to reflect the practice of administering homely remedy medicine must be available at the home. The adult protection policy must be revised to comply with the Birmingham Multi Agency guidelines. The manager must provide training for staff in protecting vulnerable adults from abuse. Previous timescale of 31/5/05 not met, this requirement is carried forward. A system to adequately protect the finances of residents including personal allowance and benefits must be in place. Money due to residents in respect of benefits must not be paid into the owners bank account(s). A programme of refurbishment and redecoration for the residents rooms must be devised and work completed. Seating and carpets in the smoking room where burnt by cigarettes must be replaced. All residents rooms, including those on the ground floor must have appropriate curtains on windows to maintain their privacy. The home must ensure that residents rooms have; 1) Adequate storage available. 2) All windows kept clean. 3) Comfortable seating. 30/9/05 30/9/05 13. YA23 13(6) 31/10/05 14. YA24 23(2)(b)( d) 30/9/05 15. YA26 23(2)(d)( e)(i) 31/8/05 31/8/05 The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 26 16. YA30 13(3) 4) Clean flooring. Toiletries belonging to individual residents in communal toilets and bathrooms must be returned to the residents room after use. Appropriate hand drying (e.g. paper towels) facilities must be available in all toilets. 31/7/05 31/7/05 The garden area and window sills 5/7/05 must be maintained in a clean and hygienic condition at all times. A risk assessment must be developed and shared with 7/7/05 the staff team to reduce this risk. An appropriate recepticle must be used to hold clinical waste bags. 31/7/05 17. YA33 18(1)((a) All equipment used for food must 31/7/05 be kept clean. 31/7/05 The manager must ensure that at least four staff are available to meet the needs of residents at all times during the working day. Care staff must not be allocated domestic duties during day hours unless their care hours are replaced. The approach to nursing care must be reviewed, residents must receive timely, skilled and planned nursing interventions based upon the individual residents needs. The induction, which meets TOPSS standards, must be undertaken with all new staff. All staff must be trained in first aid. All staff must receive regular training in fire safety. 31/7/05 18. YA35 18(1)(c )(i) 30/9/05 The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 27 Requirements not fully assessed at this inspection and are carried forward. All untrained staff (not including trained nurses) must receive training in mental health awareness. Supervision for all grades of staff must be commenced, and occur not less than six times each year. This must include an assessment of performance in relation to roles and responsibilities. Previous timescale of 30/6/05 not met, this requirement is carried forward. Nursing staff must receive adequate support to maintain and develop their clinical practice. The introduction of a quality assurance system is required. The sluice room must be kept locked at all times. Hooks and eyes on fire doors and walls used to retain the door open must be removed. The commission must be informed of all incidents / accidents that adversely affects the well-being of residents. 30/9/05 31/8/05 31/7/05 31/7/05 19. YA36 18(2) 31/8/05 20. 21. YA39 YA42 24 13(4) 37 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 E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 28 The Firs Nursing Home 1. YA42 It is recommended that the manager audit the accident and incidents in the home at least every 3 months and following and serious incident. The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Firs Nursing Home E54 S24840 The Firs Nursing Home V237137 050705 Stage 4.doc Version 1.40 Page 30 - 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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