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Inspection on 07/06/05 for Trittiford Road Nursing Home

Also see our care home review for Trittiford Road Nursing Home for more information

This inspection was carried out on 7th 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

When a resident is ill staff notice this and make sure that a doctor sees the resident soon. Residents are supported to celebrate their birthdays and parties are held in the home. Resident`s bedrooms are well decorated and residents have many personal possessions. Staff encourage residents to take part in putting away their laundry and in making their drinks. Residents have aids and equipment to help them to move around and to help staff to move them safely.

What has improved since the last inspection?

A new bath that residents can access has been provided in the bathroom in bungalow 21. The flooring has been replaced in the bathroom. Some communal areas of the home have been redecorated. Resident`s bedrooms have been redecorated. Risk assessments have been developed and have been reviewed.

CARE HOME ADULTS 18-65 Trittiford Road - 21 - 23 21-23 Trittiford Road Yardley Wood Birmingham B13 0ES Lead Inspector Sarah Bennett Unannounced 7th June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Trittiford Road, 21-23 Address 21-23 Trittiford Road Yardley Wood Birmingham B13 0ES 0121 441 5646 0121 441 2629 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) Accord Housing Assoication Ms Karen Shanley Care Home 11 Category(ies) of 11 Learning Disabilities registration, with number of places Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Care Home with nursing, maximum 11 Service Users, Under 65 years of age (11 LD). 2. Category is Learning Disabilities 3. Three existing service users who are over 65 years of age may be accommodated for as long as the home is able to meet their needs. 4. The Manager Karen Shanley is to undertake and complete the Registered Manager Award or equivalent by April 2005. Date of last inspection 13th December 2004 Brief Description of the Service: The home comprises of two purpose built bungalows. They are home to eleven adults who have a learning disability and additional physical needs. The bunglaows were purpose built in 2000, with the accommodated residents in mind. The homes aim to run independently from each other, although some sharing of staff and resources does occur. The providers have discussed seperating the two bungalows into separate registrations. The homes have been well designed and adapted to meet the residents needs. Facilities include assisted baths, ceiling track hoists in some bedrooms and mobile hoists. All the bedrooms are single occupation. Both homes have a relaxing lounge area and small sun lounge. To the rear of both homes is a pleasant garden with some raised beds to enable wheelchair access. Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by two inspectors over five hours. A tour of the premises in each bungalow took place. Care, staff and health and safety records were looked at. Four residents records were sampled. Ten residents and seven staff on duty were spoken to. What the service does well: What has improved since the last inspection? A new bath that residents can access has been provided in the bathroom in bungalow 21. The flooring has been replaced in the bathroom. Some communal areas of the home have been redecorated. Resident’s bedrooms have been redecorated. Risk assessments have been developed and have been reviewed. Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 6 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. Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 The system to inform staff what individuals needs are is not adequate and could lead to individuals needs not being met consistently. Residents are not always supported to make decisions about all aspects of their lives and this fails to fully respect their self-determination. Appropriate risk management by the home enables residents to enjoy good access to home and community activities. EVIDENCE: Residents records sampled included a photograph of the resident. Care plans sampled indicated the needs of individual residents but did not always indicate how care was to be given to each resident. Resident’s records sampled included individual foot care programmes. However, there was no indication that these were being delivered to individuals. One care plan sampled did not state how, when or by whom the care was to be given and where care offered was to be recorded. One residents care plan sampled stated that their goals were to “promote healthy lifestyle” and “ promote diet for diabetes.” However, it did not state what their target weight or target blood sugars are. Their diabetes plan stated, “ staff to be aware what to do if blood sugars are too high or too low.” However, it did not state what the target blood sugars are or what staff should do. Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 10 In the daily records sampled for one resident only ten of the fourteen days records had been completed. Another resident’s records sampled for nineteen days only fourteen of the day records had been completed. No written evidence was seen of residents being consulted about their care plans or their life in the home. Staff were observed asking residents to make choices about food, what they did and where they were sitting in the home. Risk assessments sampled for the continence needs of one resident did not cross - reference with their care plan. One residents records sampled indicated that the resident was scared of dogs. However, there was not a risk assessment in place detailing the staff support to be given to minimise the risk of this causing distress to the resident. Risk assessments were available for each resident. Risk assessments were reviewed and where necessary updated to reflect any changes. Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14, 15 & 17 The range and quality of activities available to residents in order to promote their personal development fail to involve them in the local community. Arrangements are in place to support residents to have appropriate family relationships. Residents are not offered a healthy diet, which could compromise their wellbeing. EVIDENCE: Staff were observed encouraging residents to help make drinks and put away their laundry as much as they are able to. No activities were offered to residents during the inspection of bungalow 21. Staff said that one resident had recently celebrated their birthday and a party was held in the home. Staff had filmed some of the party and were observed putting this on to video for the resident to watch. On arrival at bungalow 23 at 4pm staff said that there were no further activities planned for the rest of the day. Staff said that residents had been sitting in the garden during the day. Some residents were watching television in the lounge. Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 12 One resident’s daily records sampled indicated that in ten days the resident had been out of the house once to visit the Safari Park. Other activities they had participated in during the ten days were music therapy and watching a DVD. Another residents records sampled for a five week period indicated that they had been out of the home four times, twice for a walk, once to a doctor’s appointment and once for a drive to a local shopping area. Another residents records indicated that in a five week period they had been out of the home eight times, three times for a meal out, once for a doctors appointment, once to the hairdressers, twice for a drive and once to the Safari Park. Staff said that residents participate in the City College programme. One resident is doing gardening as part of their college programme and was observed picking herbs from their garden with support from staff. Residents records sampled indicated that where appropriate residents relatives visit them at the home. Staff said that no holidays have yet been planned for residents because of funding issues and residents not having access to their money. Staff said they are planning day trips each week for residents. In one resident’s records of food sampled only nine of the eleven days had been completed. Other records of food sampled indicated that the recommended daily intake of five portions of fruit and vegetables each day was not provided. The minutes of a staff meeting indicated that staff had discussed a low fat diet for one of the residents. However the resident’s record of food provided did not demonstrate that a low fat diet was being provided. In bungalow 23 tea was served at 5.10pm. Where needed adapted crockery and cutlery was provided for residents. Staff sat with residents and supported them appropriately. Drinks were provided with the meal. Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Residents do not always receive personal support in the way they require. The physical health needs of residents are not always adequately met. Arrangements for the management of the medication are not sufficient to ensure residents are protected from harm. EVIDENCE: In residents records sampled pressure area assessments had been completed. However, these were not all dated, signed or reviewed. In bungalow 21 staff moved one of the residents from a beanbag on the floor to their wheelchair. No hoist was used. Staff used an underarm lift, which could cause injury to the resident and the staff. Manual handling risk assessments sampled had not been regularly reviewed and updated where there are any changes. Staff said that one resident was unwell and were regularly observing them. A prompt referral was made to the GP who visited the home during the inspection and advised staff on care to be given. Records of bowel movements sampled were well documented. In one resident’s records sampled a record that they had seen an optician was available. Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 14 However, there were no records of dentist, GP or chiropody appointments. Other residents records sampled indicated that they have check ups with the dentist and chiropodist and other health professionals including the physiotherapist, district nurse and speech and language therapist are involved in their care. Where appropriate residents are seen by the dietician and are regularly weighed. Health Action Plans are not available for residents, which could compromise their well-being. Records were sampled for a resident who has epilepsy. A protocol was in place for this resident. However, this was not fully completed and had not been signed by the doctor involved in developing it. Some residents are prescribed PRN (as required) medication. However protocols stating when and how much of the medication is to be given were not in place for all residents. One resident’s medication records sampled included a protocol for as required medication. This was written in January 2005 and stated that it should be reviewed every three months. However, there was no indication that this had been reviewed. Medication is stored in a locked cabinet in each bungalow. Three non – blistered medications were audited. Two of these cross – referenced with the medication administration records. For one, 28 tablets had been received and records indicated that 22 tablets had been given. Therefore, there should have been six tablets left in the pack, however there were only four. There was no evidence that regular medication audits are being undertaken in the home to ensure that medication is being given as it is prescribed. Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 Arrangements for making complaints are not adequate to ensure resident’s views are listened to and acted on. EVIDENCE: The home uses the complaints policy of the South Birmingham Primary Care (NHS) Trust. The complaints policy has been identified at previous inspections as needing developing to ensure that residents are aware that they can complain to the CSCI at any time. This remains outstanding at this inspection. Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27, 28, 29 & 30 The condition of the communal areas of the home does not enable residents to live in a homely, clean and comfortable environment. Resident’s bedrooms suit their needs and promote their independence. Residents have the specialist equipment they need to maximise their independence. EVIDENCE: The dining table and chairs in the kitchen in bungalow 21 were in good condition. The kitchen cupboards were in a poor condition of repair, some drawer fronts were missing and others were loose. The area where there was previously a breakfast bar needs making good. The seals on the fridge doors in both bungalows were broken and in need of replacing. An offensive odour was noted in the lounge of bungalow 21 from the furniture and carpets. The carpets were heavily soiled. Staff said that the lounge and hall carpets and the furniture in the lounge are going to be replaced. Staff said that funding has been agreed for the kitchens to be refurbished in both bungalows. A new bath suitable for the residents to access has been provided in bungalow 21 since the last inspection. New flooring has also been provided in the Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 17 bathroom. The bathroom is decorated with transfers on the wall to make it look less clinical and more homely. In the shower room of bungalow 21 the blind was broken and needs repairing to ensure the privacy of residents. Staff said that the shower in the shower room does not drain away properly so that when they are supporting residents in that shower too much water accumulates on the floor. They said that the Housing Association is aware of this. Resident’s bedrooms were decorated according to individual tastes and interests and contained personal possessions. In bungalow 21 staff said that some bedroom carpets are going to be replaced. These were soiled and worn. The hammock in the garden of bungalow 21 was broken and needs removing to ensure that no residents use it. In the rear garden there are grassed areas, raised flowerbeds and patio areas with garden furniture. In bungalow 23 the lounge carpet was stained. Staff said that resident’s bedrooms have been redecorated. Resident’s bedrooms were personalised. One bedroom has not been redecorated. Staff said this is because the resident does not have access to their money. This is currently being sorted out so that the resident can buy some personal belongings when their room is redecorated. The kitchen cupboards were in poor repair in bungalow 23. Staff said that these are going to be replaced and new curtains are also going to be provided in the kitchen. In the lounge in bungalow 23 there was a hammock. Staff said that one resident did use this, however it is no longer suitable for them. This took up a large amount of space in the lounge and must be removed. Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 35 The arrangements for staffing the home, their support and development was variable. All staff vacancies need to be filled to enable residents to be supported by an effective staff team. EVIDENCE: Staff spoken to in bungalow 21 said that there is a minimum of three staff on each shift and if possible there are four. There is always a qualified nurse on duty. Rotas seen in bungalow 21 showed that minimum levels for the week ahead were not met. Staff said that staff working extra hours or bank staff would cover these shifts. Rotas seen in bungalow 23 indicated that a qualified nurse was on duty each day. Many of the staff work long days and therefore need a break during the day. During break times the staffing levels drop to below the minimum staffing level required. Therefore, a risk assessment is required to ensure the safety of residents during these times. The managers’ hours were not indicated on the rota. Staff in bungalow 21 said there were no staff vacancies. However, one member of staff was on maternity leave, one was on long-term sick leave and one was on short-term sick leave. Staff in bungalow 23 said that there were three social care worker vacancies during the day and two at night. Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 19 One residents care plan stated that staff should receive training in breast cancer awareness. However, there was no indication that staff had received this. The manager said, in feedback after the inspection, that they are going to arrange for a district nurse to deliver this training. Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 41, 42 The management arrangements are not adequate to ensure that residents benefit from a well run home. Resident’s rights and best interests are not always safeguarded by the home’s record keeping policies and procedures. The lack of attention to fully operating fire safety procedures potentially comprises residents and staff safety. EVIDENCE: At the last inspection there was a manager in post in each bungalow. Plans were in place to register each of the bungalows separately. However, funding for this is no longer available. The manager is responsible for both bungalows. The manager said in feedback after the inspection that funding is agreed for short periods so that a member of staff can be the acting manager thus providing a manager in each bungalow. However, at short notice this funding is often withdrawn and a consistent service cannot be provided. Staff said that since the last inspection the issue of all residents having access to their monies has not been satisfactorily resolved. The registered manager forwarded details after the inspection of the difficulties in resolving the issues Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 21 of residents bank accounts. Despite discussions with the bank, Appointee and Receivership and benefits agency with Trust solicitors involved there has been no progress. Since April 2004 the manager states that the Trust have subsidised residents to buy clothing, toiletries, birthday and Christmas gifts and pay for hairdressing. Residents have not paid rent to Accord during this time. Fridge and freezer temperature records are being maintained by staff to ensure good food hygiene practice. However, these are not maintained regularly. The fire records in bungalow 21 indicated that a fire drill has not taken place since August 2004. Staff had tested the fire alarm weekly to ensure it is working. The fire records in bungalow 23 indicated that the fire alarm had not been tested since 23rd May 2005. Staff must test it weekly to ensure it is working. A fire drill had not taken place in bungalow 23 since 17th December 2004. Fire drills must take place at least every six months and therefore another is due by 17th June. Records indicating that hoists are regularly serviced were seen and were satisfactory. Risk assessments are in place for residents as highlighted previously. Staff often work long days and have a break during the day. During break times the minimum staffing levels in the home are not always maintained. Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 2 2 3 1 Standard No 11 12 13 14 15 16 17 x x 1 1 3 x 2 Standard No 31 32 33 34 35 36 Score x x 1 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Trittiford Road - 21 - 23 Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x 2 1 x E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 23 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. 2. Standard 6 6 Regulation 15 (1) (2) 15 (1) (2), 17 (1) (a), Schedule 3 (3) (m) Timescale for action All care plans must detail how, 31st July when and by whom care should 2005 & be given to residents. ongoing Daily records of care must be Immediate completed and be available for & ongoing inspection. as stated on the Immediate Requireme nts sheet left at the inspection All care stated in care plans must Immediate be given to residents. & ongoing 31st July 2005 & ongoing 31st July 2005 & ongoing Requirement 3. 4. 6 6, 9 12 (1) (a),15 (1) (2) 12 (1) (a), 13 (4) ( c), 15 (1) 5. 7 6. 12, 14 Risk assessments must crossreference to care plans. Risk assessments must be available for all identified risks to residents. 12 (1) (a) Methods of consulting with (2) (3) residents, about life in the home must be investigated and commenced. A record of these must be maintained. (Previous timescale of 18th February 2005 not met) 16 (2) (m, The provision of activities must n) be reviewed and increased, to ensure residents have a choice of activities from which to E54 S24900 Trittiford Road V232794 070605 Stage 4.doc 31st July 2005 & ongoing Page 24 Trittiford Road - 21 - 23 Version 1.30 7. 17 12 (1) (a), 16 (2) (i) Manual Handling Ops. Regs 1992, 13 (4) (a,b, c) 12 (1) (a), 17 (1) (a), Schedule 3 ( k) 12 (1) (a), 13 (2) (4) ( c) 12 (1) (a), 13 (4) ( c) 12 (1) (a) (2) (3) 13 (2) 8. 18 choose on a daily basis. Community presence for residents must be reviewed and work undertaken to ensure resources and staffing are available to support these. (Previous timescale of 31st January 2005 not met) A nutritious and varied diet must be offered to residents. All records of food provided to residents must be completed. All manual handling assessments must be regularly reviewed and updated as necessary. 31st July 2005 & ongoing 9. 19 10. 19 11. 12. 19 19 All residents must have regular check ups with the dentist and optician and chiropodist where appropriate. A record of these appointments must be maintained. Epilepsy protocols must be detailed, fully completed and signed by the professionals involved. Pressure area assessments must be regularly reviewed and updated as necessary. Each resident must have a Health Action Plan in line with Valuing People. All medication not blister packed must be audited. (Previous timescale of 31st January 2005 not met) Protocols must be available for all as required medications. (Previous timescale of 31st January 2005 not met) The complaints procedure must be amended to comply with the regulations. The lounge furniture in bungalow 21 must be cleaned or replaced. 31st July 2005 & ongoing 31st July 2005 & ongoing 31st July 2005 & ongoing 30th September 2005 & ongoing 31st July 2005 & ongoing 31st August 2005 & ongoing 31st August 2005 31st August 2005 Page 25 13. 20 14. 20 13 (2) 15. 16. 22 24, 28 22 23 (2) (b) Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 (Previous timescale not met) 17. 24, 28 16 (2) (j), 23 (2) (d) The lounge and hall flooring in bungalow 21 must be cleansed to a satisfactory standard or replaced. (Previous timescale of 18th Febraury 2005 not met) 16 (2) (j), The lounge carpet in bungalow 23 (2) (b, 23 must be cleansed to a d) satisfactory standard or replaced. 16 (2) ( The identified bedroom carpets c), 23 (2) in both bungalows must be (b, d) cleansed to a satisfactory standard or replaced. 23 (2) (b, The breakfast bar in bungalow c, d) 21 must be made good. (Previous timescale not met) 23 (2) (b, The kitchen fittings to both c, d) homes must be maintained to a satisfactory standard. Where necessary these must be replaced. (Previous timescale of 18th February 2005 not met) 23 (2) ( c) The blind in the bathroom in bungalow 21 must be repaired or replaced. 23 (2) The hammock in the lounge in (n), 13 bungalow 23 must be removed. (4) (a, b,c) 23 (2) (b, The shower in the shower room c, j) in bungalow 21 must drain away sufficiently. 23 (2) (d) Odour control must be achieved in the communal lounge of bungalow 21.(Previous timescale not met) 18 (1) The rota must evidence the (a), 17 actual staff on duty and that (2), adequate staffing has been Schedule provided. 4 (7) 31st July 2005 18. 24, 28 31st August 2005 31st August 2005 31st August 2005 30th September 2005 19. 24 20. 21. 24, 28 24, 28 22. 23. 24, 27 24, 42 31st July 2005 31st July 2005 31st July 2005 30th June 2005 & ongoing 10th June 2005 & ongoing as stated on the Immediate Requireme nts sheet left at the inspection Page 26 24. 25. 27 30 26. 33 Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 27. 28. 33 35 12 (1) (a), 18 (1) (a) 18 (1) (a, c) All staffing vacancies must be recruited to. 29. 37 30. 41 31. 32. 42 42 All staff must receive training in the specific needs of residents, for example, breast cancer awareness. 9 The management arrangements must be reviewed to ensure effective management is provided in bungalow 23. (Previous timescale of 14th January 2005 not met) 20, 17 Residents money must be (2), carefully managed and accurate Schedule records of this kept. 4 The manager should not be appointee for residents unless in exceptional circumstances. the role of the Appointee and Receivership department must be clarified and made clear for each resident. (Previous timescale of 14th January 2005 not met) 13 (4) (a, The broken garden hammock in b, c) bungalow 21 must be disposed of. 23 (4) (a, A fire drill must take place in e), 17 (2), both bungalows at least every Schedule six months. A record of this must 4 (14) be maintained. 31st August 2005 & ongoing 31st August 2005 & ongoing 31st July 2005 & ongoing 31st August 2005 & ongoing 30th June 2005 10th June 2005 (21), 17th June 2005 (23) as stated on the Immediate Requireme nt sheet left at the inspection 8th June 2005 & ongoing as stated on the Immediate Requireme nts sheet left at the Page 27 33. 42 23 (4) (a) The fire alarm must be tested (c) (v), 17 weekly in bungalow 23 and a (2), record of this maintained. Schedule 4 (14) Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 inspection 34. 42 13 (4) (a, c), 16 (2) (j), 23 (2) ( c) The seals on the fridge doors in both bungalows must be replaced. 21st June 2005 as stated on the Immediate requiremen ts sheet left at the inspection Immediate & ongoing Immediate & ongoing 35. 36. 42 42 37. 33, 42 13 (4) (a, c), 16 (2) (j) Manual Handling Ops. Regs 1992, 13 (4) (a, b, c) 13 (4) ( c), 18 (1) (a) Fridge/freezer temperatures must be recorded daily. All staff must follow manual handling guidelines consistently. A risk assessment must be in place detailing how the safety of residents is to be maintained during staff break times. 31st July 2005 & ongoing RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 6 30 Good Practice Recommendations It is recommended that person centred plans be explored and undertaken with residents in the home. It is recommended that domestic support be obtained to assist in maintaining a satisfactory level of cleanliness in the home. Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection 1st Floor, Ladywood House 45-56 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 Trittiford Road - 21 - 23 E54 S24900 Trittiford Road V232794 070605 Stage 4.doc Version 1.30 Page 29 - 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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