Inspection on 25/04/06 for The Shrubbery

This inspection was carried out on 25th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Shrubbery 15/09/09

The Shrubbery 22/09/08

The Shrubbery 25/07/07

The Shrubbery 23/06/05

The Shrubbery 06/04/05

The Shrubbery 06/01/05

The Shrubbery 21/04/04

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

CARE HOMES FOR OLDER PEOPLE The Shrubbery 33 Woodgreen Road Wednesbury West Midlands WS10 9QS Lead Inspector Mr Jon Potts Unannounced Inspection 09:30 25 & 26th April 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Shrubbery Address 33 Woodgreen Road Wednesbury West Midlands WS10 9QS Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 556 8899 0121 556 8899 Mr Avtar Singh Sandhu Mrs Amarjit Kaur Sandhu Bobbi Kaur Chager Care Home 15 Category(ies) of Dementia - over 65 years of age (15) registration, with number of places The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing levels are to be maintained at the following minimum levels for: (1) Between 10 - 15 residents (with dementia) A minimum of four staff during peak periods (peak periods being 8am - 1pm and 4pm - 8 and 9pm with three at all other times with the exception of nights where a minimum of two would be acceptable. This is to allow for one staff based in each area of the home throughout the day. This is a minimum and increased dependency may dictate that the staffing levels are increased appropriately. (2) For any lower levels of occupancy the registered provider must consult and agree changes to staffing with CSCI To ensure that there is appropriate and continued dementia care training for staff in accordance with the assessed needs of the accommodated residents. This is so to enable the home to meet residents’ needs and its statement of purpose. 7/12/05 2. Date of last inspection Brief Description of the Service: The home is situated on a main route between Wednesbury and the M6 and is easy to access by public transport and car. The facilities offered by Wednesbury town centre are also in easy reach. The house itself is a mature detached residence set in its own grounds and well screened from the road with ample off road car parking. The house has three floors, all accessible by lift. There are many pleasing period features that have been retained that add character and ambience to the home. The ground floor consists of two lounges, a dining room, one bedroom, bathroom, toilets and service areas (kitchen, laundry etc). The other two floors contain bedrooms, toilets and bath/shower rooms. The home has a range of adaptations that include bath hoists, grab rails, raised toilet seats, call system, although the home is not seen as suitable for a person who is a permanent wheelchair user. The home is staffed by care assistants, a cook, cleaner and handyman under the supervision of a manager. Information about the home is made available through a statement of purpose and service user guide which is given to prospective service users and also available in the foyer of the home. Information can also be verbally obtained from the manager or provider. The current scale of charges is from £392.65 to £414.00 (this as of 15/5/06). The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was carried out to monitor the homes progress following a change of service provision to include older people with dementia earlier this year. The evidence was drawn from case tracking three residents care through numerous records kept by the home as well as discussion with residents, relatives, social workers, staff and management. Other records including staff files were also examined. Evidence gathered since the last inspection of the home has included numerous discussions with the manager and provider, firstly in respect of the homes change of category, statutory notifications and regular copies of the providers documented monthly visits to home. Residents also provided additional information through comment cards. What the service does well: What has improved since the last inspection? What they could do better: There was one area where the provider has not fully met an outstanding requirement, this in respect of the full implementation of a quality assurance tool, this to ensure that improvements could be sustained. The responsible individual was confident that this would soon be in place. There were some specific areas where issues were raised where there was need for The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 6 improvement, this in respect of care planning for diabetics, more clarity from the prescribing G.P. for ‘as directed medications’, continued staff training (in particular adult protection) and some minor works in respect of the environment (see body of the report). These are all potentially issues that would have been identified through an operational robust quality assurance tool. 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 Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 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 the following standard(s): 1,2,3,5 The home performs well in respect of providing and gathering information to/from prospective service users. The homes systems for assessment of service users have improved and decisions to admit are clearly based on an informed decision by management as to whether the home can meet their needs. EVIDENCE: The inspector case tracked three residents, all admitted since the time of the last inspection. Three residents files contained Social Services single assessment care plans (but not assessments) and copies of tri-parte contracts (these in addition to the contracts between the resident and the home). The home was seen to have carried out its own assessments of residents needs prior to their admission and letters had been issued confirming the homes ability to meet these assessed needs. Contact between the inspector and the homes manager prior to the inspection day has evidenced that the home does not admit residents with needs beyond the homes abilities. Discussion with three residents evidenced that they were all able to visit the home and make an informed choice as to the service meeting their needs (this including trial The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 9 visits if wished). The information seen on those files tracked in respect of pre admission assessments was seen to carry reference to the views of the service user clearly indicating that they were involved in this process. All three assessments were seen to cover those areas detailed within the National Minimum Standards. Information about the services the home offered was available in the foyer and in some bedrooms and one relative spoken to stated that they had selected the home after a visit and discussion with home staff. The relative also confirmed they had received written information about the home. Checklists in respect of pre admission/ admission information completed were seen in the resident’s case files although there were some omissions where some information, although available, was not checked off. The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9,10 Overall the home is good in promoting residents health and personal care with the exception of a few areas of specific documentation or practice, this in respect of care plans and medication, where the home could do better. EVIDENCE: The quality of the care plans has clearly improved since the time of the last inspection with information drawn from the homes assessment into the plan in most instances. There was some concern however in respect of the care plan for resident DA as there was no detail in the plan in respect of how the home was to manage diabetes. There was also scope for improvement in respect of recording how resident’s behaviours would be monitored and logged although there was clear detail in one case file as to how staff approached identified issues with one resident having a detailed plan as to how the staff should employ breakaway techniques. Records of behaviours could be better documented so as to enable easier access to information, despite some detailed records in daily reports. Evidence of resident’s involvement in assessments now documents evidence of their involvement in the initial care planning process, but there were no resident signatures on these plans. All risk assessments in place in respect of nutrition, tissue viability, falls, moving and The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 11 handling were documented on all three case files and regular reviews of the same were seen to be in progress. Two of the care staff spoken to were aware of what personal care planning was with the third, a new member of staff, aware that there was training booked that would cover this gap in her knowledge. Records of contact with health care services showed that the home enabled access, this confirmed by residents in discussion. An audit of the homes systems for handling medication indicated that this was well managed with the following exceptions: • Some of the Medical administration records (MARS) (resident BC) carried reference to PRN medication with handwritten directions added by staff without evidence that this was the prescriber’s instructions as labels and MARs stated ‘as directed’. There was an issue prior to the inspection visit where all the medication for one resident (DA) on their re - admission to the home was not confirmed, with the result that there was a delay in taking some medication. The home was seen to have responded to this issue with the last staff meeting showing that all seniors had been told what they needed to do to prevent reoccurrence of issue. The medication procedure has now been updated to reflect this matter. • The contracted pharmacist visited the home to carry out an audit on the 20/1/06 with no issues identified at this time. None of the residents self medicate with documentation on their case file as to the reasons. All the residents spoken to stated that the staff provided them with privacy and dignity within the home and staff spoken to were aware of how to provide the same, citing appropriate examples of how this would be done (knocking bedroom doors prior to entry, explain to residents what they are doing and why, asking permission of residents, covering with towels when getting out of bath and so on). There was also reference in a number of the homes policies as to the provision and upholding of resident’s privacy and dignity. The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 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 the following standard(s): 12,13,14,15 Residents experience a good lifestyle at the Shrubbery, this matching their expectations. Contact with relatives and a friend is encouraged by staff as is choice. The food provided is to a good standard with choice available. EVIDENCE: Documentation showed that resident’s preferences as to their preferred daily was documented, as were their preferences in respect of the types of activity they liked to, or wished not to have involvement in. There were clear records of the activities that the residents actually participated in on a day-to-day basis when. Discussion with three residents indicated that they were all satisfied with the levels of activity available to them and all stated they had enough to do. The home has a separate activity/visitors room available although there was comment that one table in this room was not sufficient if a number of residents wished to partake of a specific activity based there. The home has a visiting policy this stating that visiting is as and when with no restriction on this. As stated there is a separate room that can be used by visitors if they want privacy, in addition to resident’s bedrooms. The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 13 The menus seen showed the home has a 4-week meal cycle that provides a range of set meals that provide a suitable range of nutrition, with some alternatives within this. The home also records the meals that the residents actually have, these also showing that choices were offered. Residents spoken to were very complimentary about the food stating that they can have what they want within reason, and are served in three separate areas this meaning that the meal times (observed by the inspector) are relaxed and to a degree intimate. Meals were seen to be well presented and it was noticed there was some differential in portion sizes dependent on preference. Staff were also observed offering residents choices of meals prior to serving. Residents personal choices as to food likes/dislikes are documented in case files. There was discussion with the manager as to providing pictorial menus, and activity programmes so to assist with the presentation of this information for resident’s with dementia. It was noted on food order forms completed by the manager where there were items required for the home that had not been supplied by the provider and based on the menu a small amount of the stocks necessary to provide what was documented for the tea time meal were not available (this from the inspector checking food stocks). The Responsible Individual was informed and stated he would explore this issue. The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 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 the following standard(s): 16,18 Residents and significant others are confident that their complaints will be listened to and dealt with. The manager has been proactive in dealing with concerns prior to complaints been raised. Staff knowledge of local vulnerable adults procedures could be improved although the home has systems in place to protect residents from abuse. EVIDENCE: There have been no complaints received at the home since the last inspection although discussion with a relative and residents at the home indicated that they were aware of whom to complain to and had confidence in the staff as to resolving any issues of concern. All residents spoken to identified that they would speak to staff or manager or provider if unhappy. Comment cards returned (3 received) indicated that respondents always (1) usually (1) or always (1) knew how to make a complaint although two of the respondents also said that staff listened to and acted on what they said. A Relative spoken to was well aware of the homes complaints procedure and had no concerns as to using this if they felt it was necessary. There was evidence that the home had dealt with some issues that had arisen prior to the visit pro-actively, CSCI having been made aware and kept informed of these issues, as had the appropriate resident/relative/social worker. The homes complaints procedure was seen to be on clear display in the foyer of the home, and was available in large print. The home was seen to have appropriate procedures in respect of adult protection this including the local authorities vulnerable adults procedures. The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 15 Action to be taken by staff was discussed with three of them and all were aware of what abuse was and that they should report concerns, although only one was aware that this should be brought to the attention of the local social services department if this action was not initiated by the manager. The manager was advised that staff need to be more aware of the local authorities procedures. The manager has evidenced in discussion with the inspector on a number of occasions that she is aware of the procedure to be followed where there is potential abuse. There was seen to be body maps in residents case files, these used to clearly document any instances of bruises, injuries to residents, these records found to be useful for reasons of clarity. The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Overall the environment is safe, well maintained, clean, pleasant and hygienic. There are however a few areas where improvement is required to better enhance the resident’s living areas. EVIDENCE: Overall the environment when inspected presented as homely and well maintained with some adaptation of the layout for residents with dementia. There were however a few maintenance issues noted this including: • The curtain in the lounge to the right of the entrance (as entering) needs the curtains securing so they can’t be pulled down. • The fitting of a fire surround in the back lounge would add to the ambience of the sitting area. • There was noted to be a dripping overflow outside. • From comments made to the inspector the residents would benefit from more reading lights as some have difficulty with the light in the one lounge at night. The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 17 • • The addition of a 2nd table in the activity room would provide more table sitting space if there are more than four residents in there. A clock with a larger face that is easier to see. The home has received a recent visit form Environmental services, with a revisit having taken place (this stated by the manager to be at her request). Whilst there were a few issues to address the manager was aware of these and discussed how they were to be addressed with the inspector. Hot water temperature records were checked (these carried out monthly) these all within expected tolerances. Infection control policies were seen, these acceptable and discussion with staff indicated that they understood these procedures. There was a resident with MRSA and staff were clear as to the steps they must take to prevent cross infection. All were aware of the need for effective hand washing and there was seen to be some hibiscrub (antiseptic hand wash) available in the resident’s room, this in addition to some staff carrying their own personal bottles of antiseptic hand wash. Overalls and gloves were seen to be available to staff. Seven of the staff team have completed their infection control training (distance learning) so far and the manager plans to continue this for other staff. The Laundry was seen to be fitted with appropriate equipment and hand washing facilities. Comments from residents spoken to and through comment cards evidenced that they felt the home was always fresh and clean. The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Resident’s needs are met, and they are protected and supported by good management of staffing, this in respect of staffing levels, recruitment and training. EVIDENCE: Staffing levels at the home were seen, at the time of the visits and based on the staff rota, to be consistent with the dependency levels and number of residents accommodated at the home, as well as in accordance with the condition of registration. There are additional ancillary staff available. There are currently seven staff qualified to NVQ level 2 with an additional 5 currently undertaking the qualification. Assuming minimal staff turnover this would give the home over 50 of staff with this qualification later this year. Comments from the residents spoken to indicated that they were happy with the staff and the way that they are treated and satisfied with the level of care and support. Dementia care training (distance learning and college accredited), this based on staff discussion and training records is provided when staff start at the home. Discussion with a new staff member evidenced that there is a threemonth induction, with records of the same showing that this is in accordance with national standards. Staff stated that they have training portfolios. The home was seen to have a training planner, that showed whilst there were some areas where staff training was required, this was identified with the The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 19 manager in discussion clearly aware of priorities. There was stated to be some limitations as funding for some courses through colleges was limited to one course per staff member at a time (this in respect of distance learning packages). Discussion with staff did however evidence that they had an acceptable understanding of some fundamental values in respect of care practice. An audit of the files for 3 recently employed staff evidenced that the recruitment practices of the home were sound and would protect residents. Any staff employed without disclosure were subject to a risk assessment and enhanced supervision following discussion between the manager and CSCI. All staff (with the exception of one that was at the time under enhanced supervision) had been subject to an enhanced disclosure. The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 The polices and management practices at the Shrubbery have improved significantly over the last year. There are still areas of weakness in the home’s systems for self-monitoring and continual self-improvement. EVIDENCE: The manager of the home has been registered since the time of the last inspection and has continued to demonstrate her ‘fitness’ based on the outcomes of this inspection, with notable improvement since her appointment. The improvements at the home over the last 12 months are indicative of the effect consistent management can achieve, with this manager the first one registered since at least April 2002. Comments from the staff team evidenced this with the manager stated to be ‘very supportive’ and ‘ a good manager’. There was also comment from staff that the responsible individual was supportive. From sampling of staff files it was evident that staff are supervised The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 21 (on a one to one basis), with comment from the staff team also verifying this, and indicating that they felt this was ‘useful’. The management are still working on the homes Quality assurance system although various monitoring systems have been commenced this including regular monthly audits by the responsible individual, continued consultation with residents, relatives and now staff (questionnaires, reviews, meetings), and health and safety related checklists. The responsible individual stated that he and the managers were in the final steps of pulling a complete audit tool for all the appropriate standards together. Work on the homes annual development plan also needs to commence and continue. The homes policies in respect of protecting resident’s financial interests were supported by appropriate documentation and practices (these seen in respect of the small amounts of monies kept at the home and including the resident’s comforts fund). There were seen to be extensive risk assessments of in respect of the premises and safe working practices, as well as numerous policies and procedures. Individual risk in respect of the individual were included in their case files. No unsafe practices were observed during the course of the visit to the home and staff spoken to were clear as to how to work safely in respect of those specific areas discussed. There are still some staff (based on the manager’s comments and the home’s training plan) that need training in some mandatory areas related to safe working practices, this including moving and handling, health and safety, first aid and infection control. The manager also stated that she was working to address the few outstanding issues from the recent Environmental services inspection (this mainly in respect of hazard analysis for which the manager was seen to have obtained guidance). The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 3 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 4 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 The Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement The home must obtain copies of the social workers assessment of prospective resident’s in addition to the single assessment care plans. Where a resident is diabetic there must be clear reference to this within the individual’s care plan, this detailing all implications this may have for their health care. To develop a format for clearer recording of resident’s behaviour on a day to day basis, this to inform the review of care plans and behavioural intervention techniques. All care plans must be signed by the resident or an appropriate representative to evidence their involvement in the care planning process. All handwritten directions (by staff) for the administration of medication (on medical administration records) must be supported by clear evidence from the prescribing health professional that this is accurate. DS0000004831.V291099.R01.S.doc Timescale for action 30/06/06 2. OP7 15 15/06/06 3. OP7 15 30/06/06 4. OP7 15 30/06/06 5. OP9 13 15/06/06 The Shrubbery Version 5.1 Page 24 5. OP18 13 6. OP19 23 7. 8. OP28 OP33 18 26 To make all staff more aware of the local social services department vulnerable adults procedures. To address the following issues in respect of the environment: a) Secure the curtains in the largest front lounge. b) Provide reading lamps as needed for residents so that there is sufficient light available for reading. c) To provide an additional small table in the activity room. To provide 50 of staff with an NVQ level 2 in care qualification. The registered provider must continue to develop the homes quality monitoring system as discussed at the time of the (previous) inspection(s). The system is to be fully operational by the date identified. This is a repeated requirement that was to have been originally met by the 19/5/06. It has been partly, but not fully met 30/06/06 30/06/06 31/10/06 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP4 Good Practice Recommendations To employ more visual aids to assist with residents ease of understanding, this to include such as: Pictorial menus; Pictorial Activity programmes; A large face clock and so on. To continue with training planned for staff in respect of safe working practices. DS0000004831.V291099.R01.S.doc Version 5.1 Page 25 2. OP38 The Shrubbery Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Shrubbery DS0000004831.V291099.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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