Inspection on 16/08/05 for The Friendly Inn

This inspection was carried out on 16th August 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.

Other inspections for this house

The Friendly Inn 29/10/09

The Friendly Inn 06/07/09

The Friendly Inn 19/02/09

The Friendly Inn 17/12/08

The Friendly Inn 21/02/08

The Friendly Inn 31/05/07

The Friendly Inn 15/11/06

The Friendly Inn 26/06/06

The Friendly Inn 14/03/06

The Friendly Inn 08/03/05

The Friendly Inn 24/09/04

The Friendly Inn 17/02/04

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

CARE HOMES FOR OLDER PEOPLE The Friendly Inn Gloucester Way Chelmsley Wood Birmingham B37 5PE Lead Inspector Sean Devine Announced 16 August 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. The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Friendly Inn Address Gloucester Way , Chelmsley Wood, Birmingham B37 5PE 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) 0121 779 5128 Michael John Goss Vacant Care Home 30 Category(ies) of Old Age (30) registration, with number of places The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The grounds are made suitable and safe for use by and accessible to service users, prior to use. 2. The newly fitted bathroom/hairdressing facilities are used in a way that promotes dignity and privacy for individual residents. 3. The provision of a suitable grab rail in the new corridor area be reviewed. 4. The lighting in the lounge/dining area be reviewed as discussed, during the site visit. Date of last inspection 16th March 2005 Brief Description of the Service: The Friendly Inn Care Home is a large converted former public house. Extended by the current owner in 2003, the home is now registered to accept up to 30 residents in the category of old age requiring personal care. Accommodation is provided over two floors. The home comprises of 30 single bedrooms, of which 29 have en-suite facilities. The Friendly Inn is located in Chelmsley Wood and is readily accessible to amenities such as shops, places of worship and public transport. There is an ample well maintained garden area at the rear of the building. A shaft lift provides access to the upper floor. Parking facilities are available at the front of the building and on-road parking is readily available outside of the home. The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted by two regulation inspectors on an announced basis over a period of one day. The inspectors were able to meet many of the residents who live at the home and also some of the staff and the owner. Records pertaining to services and care provided to residents were seen, a tour of the building looking at individual and communal accommodation was undertaken. Records and practices in respect of health and safety at the home were also assessed. The home does not have a current care manager, the owner is providing dayto-day managerial support for the staff and residents and at the time of inspection had been working in this capacity for two days. The owner feels it is essential to recruit a manager and a deputy manager as a matter of urgency and has started advertising for these positions. It was evident the owner will endeavour to provide adequate managerial support whist recognising his lack of care management experience he has confirmed where necessary he will seek guidance by referring to legislations and regulations, national minimum standards, good and best practice guidance and from experienced care staff at the home. The owner was also keen to take advice from the CSCI. The CSCI received numerous letters and comments prior to this inspection from residents, relatives and visiting professionals. What the service does well: Many of the comments received were very positive about the standard of services at the home, some comments included “ I have visited the home regularly for the last 18 months, I feel 100 happy with the running of the home and care given to my good friend”,” I visit at different times of the day and would recommend this home to anyone” and “ I feel it is a lovely home with friendly staff and I am made to feel welcome anytime I visit”. The GP visits the home routinely on a weekly basis and more frequently when needed. The home routinely audits the management and safety of medicines at the home and reports on findings. The owner has a clear understanding of the individual and collective needs of the residents, improvements to the environment are well planned and timely, the owner has recently extended the dining room providing extra space to allow safe access to and from this area. The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 Page 6 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 Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3,4 Residents and their representatives are provided with appropriate information to assist them to make an informed choice on whether they would like to live at the home. Residents are not made aware of how the home will meet their care needs. EVIDENCE: Sampled residents’ files all included contracts with the resident in respect of the terms and conditions of residency. These documents included a description for example of services available, fees, insurance and how to make complaints. These files included pre-admission information such as Social Care and Health assessments and care plans, they also contained records of assessments completed by the home when they have visited prospective residents. The assessments were detailed and provided valuable information for the home to decide on whether they can meet the needs of the prospective residents. As identified at previous inspection the home does not fully demonstrate its ability to meet the needs of residents, examples of shortfalls include the The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 Page 9 inadequate training of staff individually and collectively, infrequent staff supervision and also how the home gathers and uses information in respect of caring for older people to inform and improve the quality of its services. The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 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 The planned care and risk assessment process is inadequate to ensure that the care and safety needs of the residents will be met. Health care need of the residents are met through regular contact with primary care services which needs to be supported by practice in the home. EVIDENCE: The previous manager had prior to inspection forwarded examples of new written care plans developed to meet the assessed needs of residents. Minor improvements were needed to these care plans. However the care plans sampled on the day of inspection did not reflect this consultation, they did not include specific actions for staff to take in order to meet the needs of residents, for example a care plan recorded assistance with personal care, it did not state what the resident can do independently, what staff need to do and also did not state whether the assistance was needed with washing, bathing, grooming and (un)dressing. The care plans seen were completed at the time of admission, one care plan had not been reviewed since the residents admission to the home in March 2005, the other review was inadequate as it did not describe if the plan was effective or not. Some reviews completed monthly did not review the written care plan as components of the review did not correspond to a care The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 Page 11 plan. At the last inspection the registered provider was required to develop a written care plan for the management of one resident who is an insulin dependent diabetic, the care plans for this residents did not include such a care plan. As identified at the last inspection some residents do have a daily living plan which does provide very specific information for staff about the routines and preferences of the residents, unfortunately as required at the last inspection these have not been reviewed. Many sampled care plans were unsigned, they did not detail who had written the care plan or that the resident and / or their representative had been consulted and agreed with the plan of care. Some assessments completed on admission recorded that information about social needs would need to be established, five months since admission this has not been completed and no care plans have been written. It was evident from residents’ files that they are able to see their GP when needed, the GP visits routinely every week, and also arrangements are in place for residents to see chiropodists, dentists and opticians. The ex-manager has ensured that residents have a manual handling risk assessment completed, however as required at the last inspection they also need to have nutritional, tissue viability and falls risk assessments completed. It is of concern that this has not been done. At previous inspections the home has been required to provide staff with training in respect of privacy and dignity, evidence of such training was not available on induction or upon training records. The medication practices at the home have been improved since the visit of the pharmacy inspector in March 2005, including the development of policies and procedures, having copies of GP prescriptions and having an auditable stock system in place. Further improvements from that inspection are needed including monitoring and recording the temperature of the medicines fridge, providing a control drugs cupboard, recording controlled drugs in an appropriate register and recording the date of when creams / ointments are opened. The policies need to reflect the homes practice in managing controlled drugs and also how staff are trained. At this inspection some good practices were evident including monthly medicine audits by the ex-manager which need to be continued, the audits however need to include action plans to detail how concerns raised in the findings are to be improved, it may be good practice to discuss these with the supplying pharmacist. Some findings on these audits are of concern and must be improved as a matter of urgency, these include missing stocks of medicines and unclear dosages (whether 1 spoon or 2 spoons of medicines) this must state how many millilitres of medicine are to be given. The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 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) 12,13,15 Residents are supported in some areas of their daily lives including having nutritionally well balanced appetising meals and keeping in contact with important people in their lives. Residents are not provided with individualised programmes of daily activity, thus their social, recreational and aspirational needs are not met by the home. EVIDENCE: The home has details on the wall in the office of a basic activity programme that take place on a daily basis, at the last inspection the manager was required to ensure that suitable activities are available, and are advertised and circulated amongst the residents, this has clearly not been addressed. The comment cards / letters‘ received prior to inspection from relatives also gave cause for the activity arrangements and practice at the home to be improved, one relative stated “They appear to always just be sitting in front of the television and not getting any stimulation, there is a very urgent need to organise activities for them, as I believe it does not help with their dementia”. One resident discussed the visiting arrangements agreed with the family, this resident had no concerns about visiting. Details of visits are advertised on the notice board by the front door and also detailed in the terms and conditions of residency. The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 Page 13 Meals are provided from a well-planned menu. The menu is cyclical and several residents confirmed that they enjoyed meals at the home. One resident stated that most meals are taken in the dining area, however at times tea can be taken in residents’ rooms. The owner felt that most meals should be taken where possible in the dining area, however he was also aware of the personal choices of residents. The dining area is spacious with adequate seating for all residents; the extension also has a lounge dining area that is often used by residents living within the more recent extension. The menu as identified at the last inspection must offer an alternative meal at lunchtime. The standard of cleanliness in the kitchen area, food storage areas and in respect of equipment used to manage food is adequate and safe. Core food temperatures are recorded for all cooked meats and fridge and freezer temperatures are recorded daily, these were seen to be within safe limits. There was a good stock of all foods, where required this was appropriately labelled with use by and expiry dates. The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 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) 16,18 Residents complaints are taken seriously and acted upon with feedback provided. The policies and procedures are adequate to protect residents if concerns are identified, this must be underpinned by staff training which will ensure that policies and procedures where needed can be put into practice. EVIDENCE: The method of how make a complaint is included within the residents’ terms and conditions of residency. There is a policy and a log for complaints. The log includes details of the complaint, the investigation into the complaint and also any action taken if the complaint is upheld. The home has received three complaints in the past twelve months; these were seen to have been effectively managed by the ex-manager. The owner is not fully aware of the guidelines issued by the local authority in respect of multi-agency roles and responsibilities and also those of the staff and management at the home. It is essential that the owner and staff are familiar with this guidance and that all staff receive training in protecting residents from the risk of abuse including taking appropriate measures should abuse be suspected. The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 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) All standards. The owner provides well-furnished and maintained communal areas for residents, their rooms are individualised and provide residents with adequate facilities to meet their needs. EVIDENCE: The environment is modern in design and maintained to a high standard, areas of the home continue to be developed and at present an extension to the dining area has almost been completed and will shortly be available for the residents to use. The home has four-day rooms, which can be used as quiet rooms and also for activities and relaxation, the dining area is large and can also be utilised where needed for larger groups. The rear garden and courtyard garden have a range of seating, pleasant maturing plant life and privacy and security is afforded with fully surrounding fencing. Twenty-nine of the thirty residents rooms have en-suite toilet facilities, there are also an additional six communal toilets including a disabled persons toilet. The home has three bathrooms and four shower facilities. Improvements are The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 Page 16 needed to fully regulate the temperature of hot water from the downstairs shower and also to ensure that extraction fan units are kept free from debris. The downstairs bathroom has a hoist chair to assist residents into and out of the bath. Toilets, bathrooms and shower rooms have appropriately sited “grab” rails and the first floor is accessible from a passenger lift. Garden areas are fully accessible with no steps and ramped access for wheelchairs is provided where needed. Many of the rooms are of a standard size, they only vary depending on whether they were part of the original building or built as part of the extended premises. All rooms appear to be large and of a design to meet the needs of residents. The furniture and fittings are of a good quality with suited locks on doors, all rooms seen were carpeted and provided adequate storage space for residents as well as en-suite facilities. The heating in residents’ rooms is comfortable, thermostats to alter the temperature for each individual room are easily accessible, all rooms have under floor heating and there are no radiators. Natural lighting from large windows is not restricted and ceiling and bedside lights are adequate. The control of infection practice is generally adequate, sanitary disposal and clinical waste contracts are in place. Good hand washing facilities are available in all high-risk areas. The owner must ensure that as required by regulation that items of laundry, which require sluicing are washed at appropriate temperatures for adequate time periods. Residents need to be assisted to dispose of continence pads in the clinical waste receptacle. The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 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) All standards. Residents are not adequately protected and maybe at risk by the poor recruitment and staff training practices at the home. The residents are supported with good numbers of staff to assist in meeting their needs. EVIDENCE: Four care staff are on duty during all day hours, from 8am to 10pm with two waking night staff are on duty between 10pm and 8am. The staff roster provided with the pre-inspection questionnaire highlights in bold one member of staff, however it is unclear what this means as the roles of each member of staff are not recorded. Ancillary staff including cook, assistant cook and cleaners are also recorded on the staff roster, however the roster for week commencing 15th August 2005 does not state the actual hours worked by the cleaner(s). Training records at the home could not be adequately audited, staff do not have individual training records, some records seen did not have dates of when training was received or supporting evidence such as certificates confirming attendance. Copies of recent training in Basic Food Hygiene were seen. Some information pertaining to proposed training was available. Evidence of which members of staff have completed NVQ 2 in Care or equivalent, all safe working practice training and service specific training could not be fully evidenced. Recruitment practices at the home were of concern; sampled files included an application form. Shortfalls in recruitment practice include not having two references for all staff, no criminal records bureau disclosures (CRB) for all The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 Page 18 staff, (CRB application forms had been completed, these had been sent to the wrong address and had been returned to the home, the owner confirmed they were to be sent to the correct address immediately), no medical fitness, no recent photograph and no other forms of identity. The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 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) 31,33,35,36,37 and 38. Residents financial interests and rights are safeguarded in the home. The home is without a manager and effective leader to ensure that residents are empowered, policies and procedures implemented and that informed decisions are taken. Some health and safety issues have not been adequately addressed within the home failing to fully protect residents and staff. EVIDENCE: The care manager has recently left the home. The owner has confirmed interim arrangements as being: 1. The owner undertaking most day-to-day managerial operations. 2. Identifying a leader for each shift. 3. Advertising for a Care Manager and Deputy. Quality assurance was discussed with the owner, who confirmed that consultation with residents is conducted, however records supporting this could The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 Page 20 not be found at the time of inspection. Evidence of consultation with residents and their representatives needs to be available at the home. The safe management of residents’ money is available at the home, records were well maintained and receipts and signatures confirming transactions were evident. Staff records in respect of supervision were not available, the sampled staff files did not include information in respect of aspects of practice, philosophy of care and career development needs. Records in place for residents and in respect of the services were secured within the office at the home. The health and safety practices of the home are generally good, for example, the fire system is regularly serviced and maintained, electrical portable appliance testing is completed and the nurse call system is serviced and tested. The owner confirmed that fire drills have been completed; at the time of inspection records of the drills could not be found. Records of fire drills were not available at the last inspection. The owner was advised that wedges must be removed from fire doors and where needed after consultation with the fire service self-closing devices fitted. As identified at the last inspection fire fighting equipment including extinguishers was in need of servicing, this has not been completed. Evidence that the fixed electrical installation has been inspected and tested within recommended intervals was not available. Risk assessments pertaining to fire, premises, staff and food safety were not assessed at this inspection and will be assessed on future visits. The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 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 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 3 3 1 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 3 2 3 3 3 3 2 STAFFING Standard No Score 27 3 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 1 x 1 x 3 1 3 2 The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 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 OP4 Regulation 14 Requirement The registered provider must be able to demonstrate that the home is able to meet the needs of residents at the time of admission, and on an ongoing basis. Previous timescale of 31/5/05 not met this requirement is carried forward. The written care plans must include specific instruction for staff as to how the needs of residents following the assessment are to be met. Previous timescale of 30/6/05 not met, this requirement is carried forward. Evidence is required to demonstrate that care plans are drawn up with the involvement of the residents and/or their representative. Timescale for action 30/11/05 2. OP7 15(1)(2) 31/10/05 3. OP7 15(1)(2)( c )(d) 31/10/05 4. OP7 Previous timescale of 31/7/05 not met, this requirement is carried forward. 15(2)(b)(c The outcome of the review of ) care plans must be updated and cross-referenced into main care E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc 30/11/05 The Friendly Inn Version 1.40 Page 23 plan documentation to reflect changing needs and current objectives for health and personal care. This process must involve consultation with the resident and/or representative. Previous timescale of 30/6/05 not met, this requirement is carried forward. All care plans must be reviewed on a monthly basis. Residents with a specific health 30/9/05 need such as diabetes must have a written plan of care. Previous timescale of 30/6/05 not completed, this requirement is carried forward. The registered provider must ensure residents receive a comprehensive assessment of their care needs on admission to the home. This must include risk assessments for tissue viability and nutrition. Previous timescale of 30/6/05 not met, this requirement is carried forward. All assessments must be regularly reviewed. Care plans developed to meet oral hygiene needs must contain sufficient and appropriate information to support staff in meeting the needs of individual residents. Previous timescale of 31/5/05 not met, this requirement is carried forward. The medicine policy must reflect the practice in managing controlled drugs and also how 5. OP7 15(1) 6. OP8 15(1) 31/10/05 7. OP8 12(1) 31/10/05 8. OP9 13(2) 31/10/05 The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 Page 24 staff are trained to effectively handle medicnes. A controlled drug cupboard and controlled drug register must be provided and used where necessary. The maximum, minimum and current medicines refrigerator temperatures must be recorded on a daily basis and lie between 2°C and 8°C at all times to ensure medication requiring refrigeration complies with their product licences. All external preparations must be labelled and the date of opening recorded. It is advised that these preparations are discarded 28 days from opening to reduce the risk of microbial contamination and to ensure regular reviews of cream applications are undertaken. All eye preparations must be dated once opened and discarded 28 days from that date. Previous timescale 30/6/05 not met, this requirement is acrried forward. The registered provider must ensure that areas of concern identified in the medicine audits are adequately managed including taking appropriate corrective actions. The registered provider must ensure that all staff receive training in maintaining the privacy and dignity of residents in their care as identified in the TOPSS induction standards. Previous timescale of 17/2/04 not met, this requirement is carried forward. The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 Page 25 9. OP9 13(2) 30/9/05 10. OP9 13(2) 30/11/05 11. OP10 12(4)(a) 18(1)(c ) 30/11/05 12. OP12 14(1)(c) 16(2)(m)( n) Schedule 1(9) The registered provider must 30/9/05 ensure that suitable activities are offered to the residents on a regular basis and that these are advertised in a suitable format and circulated to the residents. Previous timescale of 17/2/04 not met, this requirement is carried forward. The daily living plans must be reviewed and updated regularly and involve the residents. Previous timescale of 30/6/05 not met, this requirement is carried forward. The registered manager must ensure that there is an alternative lunchtime meal. This must also be recorded on the cyclical menu. All staff must receive training and have knowledge of measures to be taken to adequately protect residents from the risks of abuse. All shower hot water outlets must be regulated to not exceed 43 degrees celcius. All extraction fan units must be kept free from debris. The hot water pressure in residents accommodation including en-suite shower facilities must be tested and adjusted where required. Not assessed at this inspection and is carried forward. At least one washing machine must have a sluice cycle, an action plan detailing when it is to be provided must be submitted to the commission. Previous timescale of 31/5/05 13. OP15 16(2)(i) 31/10/05 14. OP18 13(6) 30/1/05 15. 16. 17. OP25 OP25 OP25 13(4)(c ) 23(2)(p) 23(2)(j) 31/10/05 31/10/05 30/11/05 18. OP30 13(3) 16(2)(j) 31/10/05 The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 Page 26 not met, this requirement is carried forward. Used continence aids must be disposed of in a timely and appropriate manner. The staff rota must identifiy who is the senior care assistant in charge of each shift. The staff rota must identify the hours actually worked by each member of staff. All staff must have a current criminal records bureau disclosure completed. 19. OP27 18(1)(a) 30/9/05 20. OP29 19(1) schedule 2 paragraph 1 to 7. ) 31/10/05 21. OP30 12(1)(a)( b) 18 (1)(a)(b)( c)(i) (ii) The staff recruitment practice must be improved and include all information and documents listed within schedule 2 of the Care Home Regulations 2001. The registered provider is 30/11/05 required to implement formal staff training and development programme, which includes induction, meets statutory training requirements and training appropriate to the work staff are to perform. Suitable assistance, including time off, for the purpose of obtaining further qualifications must be given. Previous timescale of 17/2/04 not met, this requirement is carried forward. The registered provider must recruit a care manager that is appropriately qualified, experienced and competent. The registered provider must establish a system of reviewing the quality of care, this must include consultation with residents and their representatives. 22. OP31 8(1)(a), 9(1)(2) 24 30/11/05 23. OP33 31/12/05 The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 Page 27 This should reflect the Home’s aims and objectives and include formalised systems for ascertaining the residents views, the results of which should be collated and made public on an annual basis. Previous timescale of 17/2/04 not met, this requirement is carried forward. The registered provider must ensure that all care staff receive supervision at least six times a year, this must be recorded and be available for inspection. Previous timescale of 17/2/04 not met, this requirement is carried forward. All staff must attend twice yearly fire drills, records of staff attending must be available. All fire fighting equipment including extinguishers must be serviced yearly and after use. 24. OP36 18(2) 30/11/05 25. OP38 23(4) 18/8/05 30/9/05 26. OP38 23(4) 13(4) Previous timescales of 18/3/05 and 30/6/05 were not met, these requirements are carried forward. All fire doors must be kept 16/8/05 closed and not wedged open. Following consultation with the fire service and where advised self closing devices must be fitted to fire doors. Evidence that the fixed electrical installations is inspected and tested at regular intervals must be available at the home and a copy forwarded to the commission. 30/8/05 31/10/05 27. OP38 13(4) The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 Stage 4.doc Version 1.40 Page 28 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. Refer to Standard Good Practice Recommendations The Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 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 Friendly Inn E54_S4561_TheFriendlyInn_V237566_160805 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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