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Inspection on 10/06/05 for The Foundation of Lady Katherine Leveson

Also see our care home review for The Foundation of Lady Katherine Leveson for more information

This inspection was carried out on 10th June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 collected good assessment information and were aware of both the needs of residents and how they wish their care to be delivered. Care was delivered in a way to preserve residents` privacy and dignity with most care being given in residents` own flats. The vast majority of comment cards received thought the home was good, describing the care as `excellent` and `professional`. Staff were described as having `an outstanding attitude of love and care` and `treating people as people` by relatives. Residents equally praised staff. The home has a good robust employment processes that include application, interview, reference collection, Criminal Record Bureau(CRB) checks and induction. However the home had not retained copies of the proof of identity needed to gain the CRB check on file as required. Residents are consulted via meetings and surveys and these could be part of the process of their quality assurance. The home ensures that residents have the aids they need to assist them with their daily living.

What has improved since the last inspection?

The home has put in place a nutritional assessment to inform the care plan. The home had recognised issues of recruitment and retention of staff and had put measures in place to improve this situation. The home has installed good systems for medicine management. These need to be adhered to in all instances. The home had a programme of improvement in the individual flats to provide accessible showering facilities. The home had identified a room to provide a computer access for residents wishing to keep in touch with relatives this way and had begun to furnish it appropriately. The home was having some outside paintwork done at the time of the inspection.

CARE HOMES FOR OLDER PEOPLE Foundation of Lady Katherine Leveson Temple Balsall Solihull B93 0AL Lead Inspector Jill Brown Announced 10 June 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Foundation of Lady Katherine Leveson Address Temple Balsall Solihull B93 0AL 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) 01564 772 850 01564 778 432 www.leveson.org.uk Foundation of Lady Katherine Leveson Anne Atkinson Care Home 30 Category(ies) of Care Home registration, with number of places Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The Foundation of Lady Katherine Leveson was founded in 1674 to provide almshouses for women in need. It now provides sheltered and residential care accommodation for older men and women. The foundation, which is a charity, offers accommodation for 30 residential service users and 15-sheltered accommodation places. The Court of Lady Katherine Leveson is situated in Temple Balsall, lying between Knowle and Balsall Common. It is a listed building and the majority of service users live in self-contained accommodation in the Court Yard where they have views of the mature gardens and a secure and pleasant place to walk and sit. The accommodation is mixed, all have en-suite toilet facilities, some have a bath or shower. A number of rooms have a bedroom, small lounge, kitchen and bathroom. The Court of Lady Katherine Leveson has a Christian ethos, and although they will consider non-Christians, it is required that the service users are sympathetic to the Christian ethos. There is also a 14th Century Templar Church on the premises and service users are invited to attend the service on Sundays and other Christian celebrations. The registered provider is referred to as the Master and is an Anglican priest. Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a day in June. Two inspectors undertook the inspection and the pharmacist inspector looked at the processes for drug administration at the home. Eight residents and 1 relative were spoken to during the inspection. The inspectors spoke to the deputy and manager of the home. Thirty-two comment cards were received of which 18 were from residents, 11 from relatives and 3 from health professionals. The inspectors sampled 3 residents care records, 3 staff records, maintenance and inspection records of wiring, fire and water temperatures. Training records were viewed. Staff rotas were taken for analysis. The inspectors joined residents for a meal. Areas of the home were sampled on a tour of the property and inspected. What the service does well: The home collected good assessment information and were aware of both the needs of residents and how they wish their care to be delivered. Care was delivered in a way to preserve residents’ privacy and dignity with most care being given in residents’ own flats. The vast majority of comment cards received thought the home was good, describing the care as ‘excellent’ and ‘professional’. Staff were described as having ‘an outstanding attitude of love and care’ and ‘treating people as people’ by relatives. Residents equally praised staff. The home has a good robust employment processes that include application, interview, reference collection, Criminal Record Bureau(CRB) checks and induction. However the home had not retained copies of the proof of identity needed to gain the CRB check on file as required. Residents are consulted via meetings and surveys and these could be part of the process of their quality assurance. The home ensures that residents have the aids they need to assist them with their daily living. Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Records needed to be dated and in the case of assessment, a measure of where the assessment took place would be useful. Accessibility and review of care plans could be improved. Clear details of how care is to be provided sensitive to the resident that can be updated quickly are needed. Equally the recording of health professional visits and outcomes should be easily available so that changing care needs can be responded to. The home needs to demonstrate that residents that choose not to involve themselves in planned group activities have individual time to assist in pursuing their interests. Some risks to residents for example: - exposed hot pipe work, uneven walking surfaces and so on needed to be assessed and minimised. Some risks that had been assessed required review. At the time of the inspection all of the homes housekeepers were not at work and this was evident in some of the flats. Some of the flats required redecoration. Staff turnover had caused the home some staffing difficulties and a minority of comment cards mentioned this. There was a concern raised about the lack of senior staff available on the evening and at weekends and these areas were being attended to via recruitment. Staffing issues also have meant that the home had not met its target for staff supervision. Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 Page 7 The administration needs of the home have grown and it was clear some further assistance in this area and the development of a quality assurance system was needed. The home had not reached the 50 NVQ 2 trained target and some updating training was required for staff. 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. Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The home assesses potential residents well and the inclusive of history and preferences enables residents to voice their expectations of the placement. EVIDENCE: The home undertakes thorough assessments of potential residents prior to admission. These assessments include information on health and social needs but also on the potential residents history and preferred lifestyle that should produce individualised care plans. The place and date of the assessment was not always recorded. Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 & 10 The care planning does not enable that staff deliver care as required and this potentially puts residents at risk. However, the care is delivered in away to protect the dignity and privacy of residents. The arrangement for medication administration was variable. The lack of risk assessments for residents that self medicate could put these residents at risk. EVIDENCE: The home has care plans in place. However these are away from where care is delivered. A summary of actions needed to deliver the care and minimise identified risks was not available for staff new to residents or agency staff caring for residents. Care plans were variable one sampled was excellent with clear chart of personal care given another, did not clearly show changes in care needed. Care plans were not routinely checked on a monthly basis to ensure they were an accurate reflection of the care needed. Accident records showed that the residents did not have an undue number of falls. One resident that was falling a lot had moved into ‘the house’ where extra support could be given. The manager had begun to analyse falls and suggested amendments to the format was appropriately received. Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 Page 11 Nutritional assessments were being undertaken; no changes due to these assessments were needed or noted at this inspection. Health professionals were generally very happy with the care the home provided although one had some concerns. These concerns were staff turnover leading to concerns on the skill mix within the home and the lack of senior staff at the weekend and evening. The home accepted that there had been some staff turnover and this had caused some difficulties. The inspector was advised of some recruitment and retention initiatives to improve this situation. The home could improve records by recording health professionals’ visits; outcomes of these visits and any changes to the care plan separate from daily records. Many service users were encouraged and supported to self-administer their own medication but no risk assessments had been undertaken or regular compliance checks recorded. The records did not always reflect the administration of medicines in all instances. Secondary dispensing was found but with no supporting policy. The home was keen to implement new systems into the home to improve practice and had a good relationship with the local doctors and pharmacist. Many of the residents of the home have self-contained flats or bed-sitters and this fosters the belief that carers enter residents home on invitation only. All health consultations and for many all personal care is given within their flat. Residents have individual post boxes and many residents have telephones within their flats. Assisted bathing facilities are available in the house for residents that need extra support. One relative said that at times when there has been fewer staff, the staff never rushed residents, there is always good humane interaction and they treat the person as a person. Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 Activities were not meeting the individual needs and wishes of all the residents. A range of individual choices, good food and the welcoming of visitors have improved the residents’ lives and led to a high degree of satisfaction expressed. EVIDENCE: A relative spoke of events that had happened at the home such as strawberry tea, shopping and theatre trips and musical events. Many of the residents stayed in their flats reading or watching television as they wanted. The home has some routine activities such as music and exercise. The home is investing a computer room and is hoping to put some training on for residents so that they can use this facility. Residents comment card responses to the amount of activities offered by the home were varied with approximately half having enough to do and half wanting more activities. Records did not show the activities arranged for those not wanting or able to join in group activities. Relatives felt welcomed by the home with comments received that staff were ‘polite and professional,’ ‘outstanding attitude and care’ being mentioned. Residents are given choices: whether to join in activities arranged, choice of meals available and how the care was delivered. Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 Page 13 The meal sampled by the inspectors had choices of fish and chips or, cottage pie or salad although fish and chips appeared very popular. Diabetic bread and butter pudding as well with sugar was available and there was a further option of fresh fruit. The food was well cooked and presented. Residents are encouraged to assist themselves at meal times and appropriate condiments and tureens and so on are available. Residents spoken to were happy with the food. One comment card stated they would like a hot drink at 8pm. The home had recently surveyed residents about the provision of meals and the response seemed to be that kitchen generally responded well to concerns and suggestions. Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home took complaints seriously and acted upon them and this protects residents. EVIDENCE: The Commission has received no complaints since the last inspection. The home had one complaint and this still in the process of resolution via the home’s disciplinary procedures. The homes complaint procedure had been updated since the last inspection. Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 & 26 The homes environment was of a varying standard throughout. Some parts of the home required internal repairs and improvement to ensure a safe and homely environment for residents. Residents’ needs for specialised equipment were met and this protects residents. EVIDENCE: The home has the benefit of being situated in beautiful country surroundings and the gardens are well maintained and for the most part accessible. Areas that contain shale must be risk assessed for use by residents. One comment card stated that the lack of parking next to the home caused difficulty for visitors that have a disability. The outside of the home was having its woodwork repaired and painted at the time of the inspection. The home provides enough communal space in the main dining lounge area as most of the residents’ accommodation includes separate lounge facilities. Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 Page 16 Most of the residents’ accommodations contain assisted shower facilities. The home has an assisted bathing facility in the main house however one comment card raised concerns about its suitability for some residents. The home is proposing to have a differing assisted bathing facility on the first floor of the house. There was evidence that residents were assessed and had aids provided as the need arose. Several flats had appropriate grab rails, walking aids, large numbered telephones and so on. Flats viewed were personalised, individual and it was clear that residents brought in furniture that they wanted. It was recommended that the home’s contract with residents be reviewed to restrict levels of furniture if it became hazardous. One bedroom in the main house was small and not appropriate for a resident with moderate or high care needs and was more suited for a resident on a short stay than on a long stay. Some of the flats were in need of the carpets cleaning as none of the housekeepers were on duty that week. Some of the flats required decoration. The bathrooms had pipe work exposed, some of which were reported to get hot, these must be covered. One bath was showing a higher temperature on the hot water outlet than is deemed safe and this was to be investigated. Hot water outlets for safety purposes must deliver hot water at no more than 43 degrees centigrade. Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28, 29 & 30 Improvements are needed in staffing levels and training to protect residents. The recruitment and induction processes are robust. EVIDENCE: The home has had some turnover over staff since the last inspection including the deputy manager and this has meant some disruption to the home. Recruitment has been ongoing since this and intervening time agency staff have been used. Whilst staffing falls within the recommended staffing hours some comment cards state that this needs improving especially in the morning. Duty rotas analysed showed some shifts were not covered adequately. Duty rotas must show the role of staff on duty with a clear member of staff being in charge. From the pre-inspection questionnaire information 36 of care staff are qualified to at least NVQ2 level. Staff files needed some remedial work; proof of identity was not routinely retained, some photographs of staff were missing although there was evidence that CRB checks were undertaken. References were available but it is recommended that verification of the reference be requested by headed paper or company stamp. An application form was completed and the home kept a copy of questions and answers of the applicant. These questions covered the key areas of care practice. Residents in the home are involved in the recruitment of staff and this is commended. New staff have a full induction Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 Page 18 programme and this includes a learning log signed by the supervisor and the new member of staff and this is commended. The matrix of training of the staff group had not been updated but it was acknowledged that there were some gaps in required training but a member of staff had taken on the role of training and development and this should resolve as new staff are taken on. Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 36, 37,& 38 Arrangements for management of the home were generally good. A quality assurance system needs to be developed to ensure a consistent improvement. EVIDENCE: The home held meetings with residents and reported back outcomes of concerns from meeting to meeting. Residents were confident that they could report their concerns to both the manager and other members of staff. The home does not have a quality assurance mechanism in place at the moment this is needed to ensure that all the processes can be improved year on year. The home does have however have systems for audit and review of the catering section, activities and yearly undertakes a customer service survey. These elements can be fed into a quality assurance system. Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 Page 20 Staff have supervision however this is not always achieved at a two monthly interval due to staffing difficulties. Records at the home are safely and routinely kept. The home has more paperwork in respect of electrical supply and health and safety risk assessments than most residential homes because of how the home is built and further assistance in administration would be useful to ensure that the requirements for review are maintained. Portable electrical equipment is routinely checked. All fire tests, maintenance and drills had been undertaken. Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 2 2 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x 3 2 x x 2 2 3 Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 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 op7 Regulation 15 Requirement The care plan must record in detail how care is to be delivered and be accessible to the staff assisting the residents. Care plans must be reviewed monthly for their continued effectiveness and any changes noted on the care plan and dated. Visits by health professionals must be recorded in such as way as to make it easy for staff to note. Any changes as a result of these consultations must be noted and dated on the care plan. Any service user wishing to selfadminister their own medication must be risk assessed as able and compliance checks undertaken on a regular basis. Staff must return all unwanted medicines to the pharmacy for destruction. Staff must refer to the Medicines Administration Record (MAR) chart prior to administration and record directly after the Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Timescale for action 31/07/05 2. op7 13(1) 12(1)(a) 31/07/05 3. op9 13(2) One week and ongoing One day and ongoing One day and ongoing Page 23 Version 1.30 transaction has taken place in all instances. Any secondary dispensing must be against a policy and correctly labelled and checked by a second member of staff for accuracy. The homely remedy policy must reflect medicines purchased. 4. op12 16(2)(n) The home must demonstrate how residents that are unable to join in group activities have time spent with them. Areas of shale used as a surface must be risk assessed for residents with poor mobility. The home must consider the car parking needs for disabled visitors to the home. The small bedroom in the main house must be reviewed for use. Residents flats must be audited for redecoration and a schedule produced a copy must be sent to the Commission. Exposed pipework must be assessed for the risk of causing burns to residents and where appropriate boxed in. The bath hot water outlet that registers a hot water temperature above 43 degrees centigrade must have its thermostat adjusted to comply. Duty rotas must clearly show the role of the staff member on duty and the name of the staff member in charge for each shift. The staff on duty must reflect the needs of the residents at all Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 Page 24 One day and ongoing One week and ongoing 31/08/05 5. 6. op19 13(6) 31/07/05 7. 8. op23 op24 23(2)(f) 23(2)(d) 31/08/05 31/08/05 9. op25 13(6) 31/08/05 30/06/05 10. op27 17(2) schedule 4 (6) 31/07/05 times. 11. 12. 13. 14. op29 op30 op33 op26 17(2) schedule 4 (6) 18(1) (c)(i) 24 23(2)(d) Proof of identity including photograph of staff must be retained on file. Up dates and required training must be given to staff. A quality assurance system must be set up in the home. Carpets in several flats must be deep cleaned. 31/08/05 31/08/05 30/09/05 30/06/05 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. 3. Refer to Standard op3 op9 op23 Good Practice Recommendations It is recommended that the place and time of the assessment be recorded. It is recommended that the photocopied prescription be kept alongside the Medicine Administration Record (MAR) chart for the relevant 28-day cycle for reference. It is recommended that the home review its information and contract to ensure that limits to the amount of furniture in residents accommodation are clearly stated to prevent health and safety risks. It is recommended that the future training of staff includes NVQ2 to ensure that the standard is met. it i recom,mended that recorded supervision occurs no less often than 6 times a year. It is recommended that further administration support is given to effect the requirements made at this inspection. 4. 5. 6. op28 op36 op37 Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor Ladywood House 45/46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Foundation of Lady Katherine Leveson E54_S4517_FoundLadyKathLev_V225261_100605 - Stage 4.doc Version 1.30 Page 26 - 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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