Inspection on 09/08/07 for Valley Court

This inspection was carried out on 9th August 2007.

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

Valley Court 08/08/08

Valley Court 14/08/06

Valley Court 15/03/06

Valley Court 07/09/05

Valley Court 07/03/05

Valley Court 26/08/04

Valley Court 19/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Valley Court Valley Road Cradley Heath West Midlands B64 7LT Lead Inspector Mandy Beck Key Unannounced Inspection 09:00 9 and 10th August 2007 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 Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 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. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Valley Court Address Valley Road Cradley Heath West Midlands B64 7LT 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) 01384 411 477 01384 411470 Pepperhall Limited Joan Green Care Home 69 Category(ies) of Old age, not falling within any other category registration, with number (69) of places Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th August 2006 Brief Description of the Service: Valley Court is a purpose built Care Home, opened in 1998, which provides 69 beds for frail older people, 39 who require residential care and 30 who require nursing care. It is independently owned. The Home is located within easy reach of main routes between Halesowen, Cradley Heath and Dudley with public transport and local amenities easily accessible. It is situated next to a primary school, with a shared driveway. There is ample car parking to the front of the Home and gardens and patio areas to the rear. The Home is separated into two units, one dedicated to Residential Care, the other to Nursing Care. Shared facilities include the kitchen and laundry. Service Users accommodation is provided on two floors, all bedrooms are single, and 64 out of 69 have en-suite facilities. There are lounges and dining rooms on both units. The home currently has a range of bathing facilities, nurse call system, passenger lifts and some disabled facilities. The Home has separate staff teams; with the Registered Manager who is a first level nurse, undertaking responsibility for the Residential beds and the Nursing beds. Fees vary between £335 and £439 and are dependant on the needs of the service user and the type of room that will be occupied. The following are not included in the fee: non NHS Chiropody (£10), hairdressing (£4.50), toiletries, telephone calls and activities such as bingo (20p a book). Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the home. It lasted two days and during this time we collected evidence to help make the judgements in this report. We spent time with the residents and staff to help us find out what life is like for the people living at the home. We looked at resident’s files as part of our case tracking process. This process enables us to look at selected residents care in depth and to make decisions about whether the home is meeting their needs. Staff files were also examined to make sure that the home is continuing to recruit people in a manner that safeguards its residents. Information given to the Commission for Social Care Inspection (CSCI) in the home’s Annual Quality Assurance Assessment (AQAA) has also been included in the body of this report. Some of the comments that resident’s have made in the questionnaires we sent to them have also been included. The inspector would like to thank all of the residents and staff for their hospitality during this inspection. What the service does well: The home is welcoming and the atmosphere is very friendly. All of the residents we spoke to said that they were happy in the home. One resident said, “its lovely isn’t it and the garden is nice too”. The home is pleasantly decorated and provides a nice, relaxing place for residents to live. Staff are friendly and residents said “the staff are very good, helpful and nothing is too much trouble for them”, “they provide a unique service to each individual to meet their needs”. “The home and the staff are first class” Relatives commented “Always receive 100 support from the staff in any concerns I have had about my mother”. They also said that they felt confident in approaching the manager if they were unhappy about any aspect of their care. “On the occasions we have approached them to complain it has been dealt with actively”. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Serious concerns were expressed during this inspection about the safety of the bedrails currently in use. The manager has been asked to address this urgently so that residents are not placed at increased risk of injury. We have written to the home formally asking for their action plan to meet this requirement. In order to further develop the quality assurance system the manager needs to produce action plans to show how they will address the issues raised from their monthly audits. The home needs to continue building upon the work they have done so far in person centred planning for residents particularly on the nursing unit. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 7 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 summary of this inspection report can be made available in other formats on request. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. People who live at this home will have their needs assessed in full prior to their admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager visits all prospective residents prior to admission to complete a full needs assessment and to satisfy herself that the home will be able to meet those residents needs. Once this has been completed the resident is encouraged to spend time at the home to ensure that they will like it and make their own mind up. Typically most residents spend a day at the home or will stay for lunch so that they have the opportunity to talk to other residents. In some cases a trial visit has not been possible and relatives have made a choice on behalf of the resident, one such resident said “they made a good choice don’t think I could’ve done better”. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 10 The manager will write to residents confirming that the home can meet their needs once they move in. This home does not provide intermediate care. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. People who live in this home can feel confident that their health care needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Resident’s files were seen as part of our case tracking process. This means that resident’s care plans are examined to ensure that an assessment and a plan of care has been undertaken, that it is kept under review and that residents have been involved in the process. It was pleasing to see that all of the files seen contained an assessment of needs, in some cases there were two, one from the social worker and one from the home manager. Needs identified in these assessments had been transferred into individual care plans for each resident. In addition to the care plans the home also has risk assessments in place for the identification of malnutrition, pressure sore development, falls and moving and handling. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 12 There has been some work in developing a person centred approach to care plan writing. This was evident particularly on the residential care where we found one care plan for a resident that addressed specific communication problems. The individual care plan gave staff clear instruction about how to meet this persons needs, such as “use simple language, be patient with me if I don’t understand the first time and approach me from the front”. Other improvements to the care planning process have included contingency plans for those residents with specific health needs such as diabetes. Care plans now guide staff on what to do in case of emergency and what signs to be observant for. Short-term care plans have also been introduced for residents, these plans are kept in a separate folder but instruct staff on the care residents need during a short illness such as a urine infection or chest infection. Whilst it was pleasing to see that all of the residents on the nursing unit had care plans, there needs to be more of an improvement in person centred planning. For example care plans for personal hygiene needs stated “follow the bath rota and ensure that she has a bath weekly”. This does not show that an individual approach to planning care has been taken. It would be more informative to guide staff about the individual wishes of the resident such as their choices about when they wanted to have bath and what sort of assistance they needed during this time. It was clear however, when talking to the staff they had a good understanding of each residents needs and their individual wishes. We also spoke to residents during the inspection who were very complimentary about the care and attention they receive. They said “nothing seems to be too much trouble”, “the home and the staff are first class”. One relative said “they provide a unique service to each individual to meet their needs”. We found that the home is using bed rails to keep residents safe in bed. The manager has been in the process of replacing the mattresses on residents beds for soft foam mattresses, this will help reduce the incidence of pressure sores developing. However the new mattresses are not compatible with the bed bases and bed rails. We found that the bed rails had large gaps, which increased the risk of entrapment to residents, and they were not secured to the beds as required because the mattresses were too light. Serious concerns were expressed to the manager. We have asked for the registered provider to give us written proposals to rectify this situation because of the risk to the health and safety of residents. It was pleasing to see that the manager had begun to address this problem during the inspection. All of the residents have access to their own Doctor when they need it, the home is also supported by other community services such as dentistry, chiropody and the district nursing service. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 13 We looked at medication practices within the home and found that there are good systems in place to ensure that residents receive their medication as and when their Doctor has prescribed it. Since the last inspection the home has installed air conditioning in the treatment rooms. This means that all medicines are now being kept at safe recommended temperatures. Other improvements include the introduction of care plans for those residents who require their medications on an “as required basis”. These plans instruct staff on when it is appropriate to administer such medication. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. People who live in this home will be encouraged to take part in activities and to maintain their relationships with family and friends. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has employed an activity coordinator because there had been concerns that residents were not encouraged to participate in activities. The manager also mentioned that more in house activities were taking place. Some of the residents are involved in making greeting cards that are on sale in the reception area of the home. One resident said, “I’m so busy with it, I don’t let them go out until I’m satisfied with them they have to be perfect”. Some relatives have commented that they would like to see more activities arranged outside of the home. They said “it would be good for those who were most able were perhaps taken out occasionally to the park or theatre”, and “would like more outside trips it can be boring staying inside the home all the time”. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 15 These comments were discussed with the manager who explained that she had organised a trip to Walsall Illuminations following the last inspection but she had found it extremely difficult to fill the minibus because none of the residents wanted to go. Those residents who did go said that they had not enjoyed it. Every resident now has their own activity plan that details their hobbies and interests, this information is used by the activity coordinator to plan activity for residents. There is no formal plan of activity at the present time. All visitors are welcomed to the home and during this inspection a steady flow of visitors were observed coming in to see the residents. One relative was very complimentary about the care her husband had received, “I am taking him home next week for good, I never thought I would say that but the staff have worked wonders with him, they are excellent”. We spoke to residents about how the home supports them, one resident said “they are helping me to decorate my room how I want it doing, they encourage me to go out and visit my friends”. Meal times are relaxing and staff work hard to provide the assistance each resident needs. All of the dining rooms have been redecorated and are much improved since the last inspection. Residents are individually assessed for their risk of malnutrition and appropriate action taken where risks have been identified. The home operates a four-week menu, most of the residents were happy with this. As a result of a recent residents meetings more bacon has now been placed on the breakfast menu for residents to enjoy. Everyone we spoke to said that the meals were tasty, that there were always two choices and the cook is willing to offer them an alternative if they don’t like what is on the menu for that day. One resident said, “my tea was served luke warm, I mentioned it and it is always hot now when it comes to me”. The home is also able to cater for residents with special dietary requirements. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. People who live in this home feel confident that their views will be listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As in previous inspections the complaints policy is displayed prominently for all residents to see and access. All residents have a copy of the complaints policy and a procedure in their bedrooms along with the service user guide. In addition to this there is a suggestions/comment box on the reception counter for people to use if they choose to do so. The CSCI has received no complaints about the home or the service it provides since the last inspection. The manager has now updated the homes policy for the care and protection of Vulnerable adults, staff have received training in recognising abuse and what to do if abuse is suspected. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,26 Quality in this outcome area is adequate. The home is well maintained, clean and hygienic. Improvements are needed to the provision of equipment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been a lot of improvements to the home since the last inspection. Most notably was the landscaping of the garden, which looked beautiful on the day of inspection. The home has put a lot of thought into providing a stimulating sensory garden, with wind chimes, scent plants for residents to enjoy. The weather was very warm during the inspection and it was pleasing to see that a lot a residents had taken the opportunity to sit outside in the warm and enjoy the garden. One resident said “you should see it at night the lights come on and its lovely”. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 18 Internally, new flooring has been provided in the main corridors, some bedrooms and all of the dining rooms. New curtains have been put up in Sandringham lounge and there are plans to replace the carpet in the near future. Some residents have raised concerns about offensive odours around the home at times. The manager did say that in an effort to address this they have purchased a carpet cleaner to make sure that spills are cleaned up promptly to avoid bad odours occurring. The manager has also been able to purchase three new pressure relieving mattresses for residents comfort and two new hoists have also be supplied to enable staff to move residents safely and to reduce the risk of injury. One area where we highlighted serious concerns was the use of bed rails. We found that residents were inadvertently being placed at risk because mattresses, bed rails and beds were not compatible with each other. As a result this had left bed rails unstable and with large gaps that increased the risk of entrapment to residents. This was bought to the manager’s attention immediately who will now address this situation. The manager has been replacing all of the divan mattresses with soft foam pressure relieving mattresses to help manage the risk of pressure sore risk development unfortunately this has made the bed rails unsafe and this must be addressed. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. The people who live in this home can feel assured that there will be enough staff to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels remain under continuous review. The manager increases the staffing as residents needs change. The reduction in usage of agency staff continues and as a result residents are experiencing more continuity in their care. After having seen the home’s duty rotas it appears that staff are supplied in sufficient numbers to meet the needs of residents but the manager but be aware of staff working excessive hours and the effects this may have upon the care workers. The home continues to support its care workers who are undertaking their National Vocational Qualifications (NVQ) and it is making progress in achieving 50 of care staff having this qualification. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 20 Staff files were examined to ensure the home is continuing to recruit people in a safe manner and it was pleasing to find that all of the required information was present. Staff are checked thoroughly before they are allowed to begin employment at the home. Criminal Record Bureau (CRB) disclosures were available for all staff. The manager was asked to clarify whether the home has a policy for renewal of CRB’s after a letter in one workers file stated that this would happen after three years. If this is the case then it is possible that 27 of the current staff group will need to have their CRB’s renewed. There have been improvements to the induction process for new workers, the new induction programme is now compatible with the Skills for Care induction standards. New workers are supported throughout their induction by senior care staff and nurses. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. The home is well managed and the people who live here can feel confident that it is run in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home continues to be managed by Mrs Joan Green. Residents and staff are very complementary about her and the way the home is managed. They said “she helps us if we have any problems”, “we do feel supported by the manager when we are at work, I think she is fair”. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 22 Both the manager and deputy manager should be commended on the hard work they have undertaken in establishing a quality assurance system in the home. Regular monthly audits are undertaken on accidents, incidents, and the home environment. Once the results from these audits is collected they are then put into graph form and provide the manager with “at a glance” information. Further development is needed in order for the manager to be able to show how she will action some of the issues raised as a result of these audits. For instance a high number of falls was recorded on one unit, the manager had taken appropriate steps to address this problem but had not formally recorded them. Residents are consulted on a yearly basis about their views about how the home is run and whether they have suggestions on improvements that could be made. The most recent surveys are in the process of being returned. Some of the comments received were very positive. “The staff are what make the home good, they are brilliant, more regular toilets checks could be done but generally the care is very good”. “Staff operate in a respectful, friendly and empathic manner”. “The standard of cleanliness is excellent, would it be possible to replace wheelchairs, privacy can be difficult when visiting this could be improved. I have breakfast upstairs I would appreciate the tea being a bit warmer”. It was pleasing to note that once these issues had been raised residents were able to confirm that they had been addressed by the manager. Maintenance contracts and records were up to date. The manager has now improved the recording of hot water temperatures for the whole of the home. this was a requirement from the previous inspection. There are good systems on place to ensure that staff receive mandatory training that will help to keep their knowledge and skills up to date. Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 23 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 2 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 X X 3 Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13(2) Requirement To ensure that there are two signatures to witness hand written MAR sheets (Previous timescale of 31/10/05 not met (nursing unit) Timescale for action 20/09/07 2 OP27 13(4) 1) To ensure that yellow clinical 20/09/07 waste bags are disposed of in a secure container in a secure area 2) To ensure that there are sufficient collections of clinical waste to avoid overflowing containers (Timescale of the 01/05/06 not met clinical waste bins were unlocked and were seen to be overflowing.) 3 OP38 13(4) To provide a bedrail risk assessment / evidence of regular checks for all rooms where they are in use. (Previous timescale of 01/05/06 not met) Residents, who need bed rails, must have them checked and DS0000004829.V339440.R01.S.doc 01/09/07 4 OP38 13(4) 01/09/07 Valley Court Version 5.2 Page 25 made safe. Bed rails must be compatible with the bed and mattress being used. (Immediate requirement) 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 OP3 Good Practice Recommendations The element of the terms and conditions of residency that specifies that belongings left at the home were liable to a storage fee is being reviewed. Not assessed during this inspection. Residents care plans on the nursing unit need further development to ensure that they are person centred in their approach. Staff need to record on the MAR sheet the exact number of medication that has been received and not rely on the pre-printed number supplied by the pharmacist. That the rarely used bathroom on the residential unit should be changed into a walk in shower facility to give service users a choice of showering or bathing The manager must be mindful of the amount of excess hours staff are agreeing to work. Excessive hours may lead to staff being tired and not completing their duties to the best of their abilities. 2 3 4 5 OP7 OP9 OP22 OP27 Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Halesowen Local Office West Point Mucklow Trading Estate Mucklow Hill Halesowen B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Valley Court DS0000004829.V339440.R01.S.doc Version 5.2 Page 27 - 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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