Inspection on 26/04/05 for Willow Grange

This inspection was carried out on 26th April 2005.

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

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

Other inspections for this house

Willow Grange 28/05/08

Willow Grange 30/04/07

Willow Grange 09/01/07

Willow Grange 14/09/05

Willow Grange 13/01/05

Willow Grange 28/07/04

Willow Grange 14/01/04

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 Willow Grange 119 St. Bernards Road Olton Solihull B92 7DH Lead Inspector Amanda Lyndon Unannounced 26 April 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 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. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Willow Grange Address 193 St. Bernards Road Olton Solihull West Midlands B92 7DH 0121 708 0804 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) Alpha Health Care Ltd Ms Nicola Jayne Davis Care Home 46 Category(ies) of Old age, not falling within any other category. registration, with number of places Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That Miss Davis obtains the required management qualification, i.e Registered Managers award / NVQ 4 in Care Management by 2005 Date of last inspection 13 January 2005 Brief Description of the Service: Willow Grange is a residential care home registered for forty six older people, located in the Olton area of Solihull. Following assessment, the home are able to accommodate older people for both long stay and respite care. The home is located near to a bus route and places of worship. Willow Grange is a large Edwardian house which has a purpose built single storey extension to the rear of the property. An adjoining coach house is also incorporated in to the property. All bedrooms with the exception of six of the single rooms have en suite facilities (shower, wash hand basin and toilet). The home has five double bedrooms, thirty six single bedrooms, kitchen, dining and seating areas, laundry and hairdressing salon. The home has a passenger lift. There are car parking facilities to the front of Willow Grange and gardens to the side and rear of the property and an inner courtyard. The home has a varied activities programme on offer. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken by one Inspector over the period of one day. There were 43 residents living at the home on the day of the inspection and the Inspector met with a number of these people. Information was gathered from speaking with the residents and staff, observing the care staff perform their duties, examining care records and by undertaking a tour of the home. There had not been any changes to the management structure within the home since the previous inspection. The majority of the residents met during the inspection expressed their satisfaction in respect of the service provided at Willow Grange. Part of this inspection involved investigating a complaint received by the Commission from the relatives of a resident who had recently moved from the home raising issues regarding aspects of care delivery and residents’ dignity. A number of the elements of this complaint were not upheld and the Manager has devised a plan of action to address the areas of concern that were upheld. What the service does well: Assessments are undertaken by staff to ensure that the home can meet each resident’s care needs. Residents are given information about the terms and conditions of their stay and these detail what is included and excluded from the fee. Residents are generally well supported by the care staff to meet their health, welfare and personal care needs and are cared for in a respectful manner. One resident said “ I can’t say anything against the staff, they are respectful”. Residents can make decisions regarding their daily lives. One resident said “I choose to have most of my meals in my room because I have a medical condition and the staff are understanding about this”. Residents are invited to regular meetings to discuss the service provided at the home. There is a wide variety of activities on offer at the home for the residents to participate in should they choose. In general, Willow Grange provides a clean and homely environment for residents to live in. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 3 4 Residents know before admission that the home can meet their care needs through the assessment process. Residents are issued with a contract to ensure that they are informed of the terms and conditions of their stay at the home EVIDENCE: Pre admission assessments are undertaken by senior staff for all prospective residents. The document used for this did not include all of the information required and a number of these were not completed in full. Prior to admission to Willow Grange, residents are issued with a letter from the home stating that they are able to meet their identified needs following the pre admission assessment. Each resident had a statement of terms and conditions of residency and this included all of the information required The home arranges for residents to be re assessed should their care needs change or if they ready to return to the home following a stay in hospital, to ensure that the home could continue to meet their care needs. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 8 9 10 Resident’s health and personal care needs were generally well met however changing needs were inadequately monitored and documented putting residents potentially at risk. Not all medication was stored in a safe manner and this may pose a risk to residents’ safety. EVIDENCE: Elements of the complaint received alleged that the standard of personal care provided at the home was poor. The Inspector evidenced that the standard of care at the home was good, however written evidence of this through the care planning system was not available. Holistic assessments had been undertaken for each resident living at the home, however, these had not always been developed into care plans. Care plans detailing how the care staff can meet the residents’ identified care needs were not available in three of the four care files sampled. Not all moving and handling risk assessments had been reviewed to reflect the residents’ current abilities and these did not include detail of the action to be taken should a resident fall. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 10 One care plan stated that a resident enjoyed having a shower at the home, however, this person had informed the Inspector during the inspection that this was no longer the case and the care plan had not been updated to reflect this. Care plans for medical conditions did not include detail of how to monitor the care for the individual person’s needs. Personal risk assessments were often poorly completed, did not include the name of the resident, were not dated and a final risk score or rating was not identified. Residents have access to Health and Social Care Professionals including their General Practitioner, district nurses, social workers and opticians and a record of their input was maintained, however the Inspector could not evidence that residents’ acute health care needs were monitored by the care staff and not all residents were weighed regularly. Some of the written daily reports included detail of the activities that the resident had engaged in during that day, however, others were found to be non informative. Pressure relieving equipment is obtained from the district nursing team. Not all bedrooms contained a lockable storage facility. A small number of residents had chosen to hold the key for their bedroom door, however, risk assessments had not been undertaken to identify the reasons why other residents did not hold their own key. Residents were dressed appropriately for the time of year. One resident said “ I can’t say anything against the staff, they are respectful”. The Inspector saw that medication a resident had chosen to self administer was not stored safely and not all medication was labelled and this is despite a self medication risk assessment being undertaken. Medication trolleys were not stored securely. On the day of the inspection, the supplying pharmacy were undertaking their audit of the system for the management of medication at the home. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 14 15 Meals provided at the home are well balanced and nutritious, however are presented poorly on occasion which may impact negatively on the residents’ appetite. Residents are able to exercise their choice over their daily lives and the activities that they choose to participate in which promotes their independence and individuality. EVIDENCE: Residents’ bedrooms contained many personal items and reflected their individual tastes. The main meals of the day were nutritious and the residents had a choice of two options. A record of food provided for each resident was maintained. One resident said “ The food is more nice than bad” Residents are not given the option of serving their own food portions at the dining tables. One resident said “ The presentation of the meal and the speed of serving is poor and too fast”. Residents can choose where they have their meals. One resident said “ I choose to have most of my meals in my room because I have a medical condition and the staff are understanding about this”. Dining tables were laid attractively with condiments available. One resident said “ I went out for lunch on Sunday and when I returned a tray of tea came to my room, I was so happy”. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 12 The home employs a part time activities coordinator and there was a wide variety of activities on offer including, a weekly trip to a tea dance, pub lunches, bingo and in house games. A hair dresser visits at least weekly and Holy Communion is available weekly. There is a trolley shop containing personal items for the residents to purchase and this is open daily. Each resident is issued with their own copy of the activities that are available each month. A comprehensive record of activities was maintained. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 17 18 The home has robust systems in place to protect residents from abuse. The complaints procedure is comprehensive and is accessible to the residents should they need to make a complaint. EVIDENCE: The complaints procedure was prominently displayed in the home and this included all relevant information. One resident said “ I would talk to my daughter if I wasn’t happy about anything”. Another resident said “ I would speak to the manager if I had a complaint”. The home had not recorded any complaints since the previous inspection. The home had received a number of compliments. The adult protection procedure had been amended since the previous inspection and whilst this included the majority of relevant information, the Registered Manager stated that she is waiting for local authority guidelines in respect of this to be issued and subsequently the home’s adult protection and whistle blowing policies will be further developed. All staff had satisfactory enhanced police check clearance and had received training about elder abuse. Residents are able to vote in elections either by post or in person. The Registered Manager is aware of how to access advocacy services should the need arise. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 21 24 25 26 Willow Grange provides a homely and comfortable environment to live in which residents are relaxed and secure. The home does not have an assisted bathing facility and the showering facilities are inaccessible for a number of residents to use, and this limits the residents’ choice and does not promote their independence. EVIDENCE: The majority of service users had an en suite toilet and shower facility, however the majority of service users were not able to use their shower independently as they had to negotiate a step up into them. One resident said “ I was looking forward to having a shower but it is unsatisfactory here so I don’t have a shower at all”. There is one communal shower facility on the first floor of the home however the space within this room is limited, a raised toilet seat was not available, and although grab rails were in place these were fitted too far from the toilet. There was no space between the clinical waste bin and the toilet and on the day of the inspection, there was a stale smell within this area. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 15 A number of residents expressed their dissatisfaction at not having a bathing facility at the home. One resident said “I would be in the front row for a bath. I can’t manage the shower independently” One element of the complaint received alleged that the home had failed to observe that a resident’s own wheelchair had been used to transport another resident to hospital and had not been returned. This element of the complaint was upheld. An element of the complaint received alleged that standards of cleanliness at the home were poor. This element of the complaint was not upheld as the home was generally clean and fresh on the day of the inspection with the exception of one bedroom and the communal shower room. There was soiled incontinence pads in an inappropriate waste paper bin in an en suite facility that was used by two residents. An element of the complaint received alleged that commodes were often not emptied after use and were left uncovered in the resident’s bedroom. The outcome of this was unresolved as this practice was not observed on the day of this inspection. There were three cleaners on duty and the residents met during the inspection expressed their satisfaction at the level of cleanliness at the home. One resident said “ They clean my room every morning”. There were hygienic hand washing facilities in the home with the exception of the visitors’ toilet. An effective and hygienic laundry service for residents clothing and bed linen was in place. New carpets had been fitted in a number of communal areas in the home and an appropriate hard floor covering had been fitted in the dining area. The dining area did not provide adequate seating for all residents who chose to be served their meals in there and the Registered Manager stated that an extension to this area was being reviewed. A record of furniture provided for each resident was maintained. Furnishings and fittings were generally of a good standard in the home with the exception of curtains in a resident’s bedroom which were found to be torn and water stained. Since the previous inspection, guards had been fitted to the radiators in the communal areas of the home that the residents have access to, however, guards had not been fitted to radiators in residents’ bedrooms. The lighting was adequate in the home with the exception of one en suite bathroom in which the lighting did not work. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 30 The home provides staff in adequate numbers to meet the needs of the residents. Staff undertake training to improve their knowledge of caring for older people. EVIDENCE: The home had a vacancy for a handy person. One resident said “ The staff are very good to me, I think that I am a nuisance but the staff assure me that I am not”. Staffing rotas identified that the home were working within approved staffing levels. The Registered Manager stated that the home had not used temporary or agency staff recently. With the exception of one person who chooses to do so, staff do not work an excessive number of hours per week at the home. Plans are in place for a revised staff induction programme to commence at the home. Staff had undertaken training specific to the role that they perform including infection control, customer care and care planning, however, the Registered Manager identified further staff training issues following the recent complaint received by The Commission. A training needs analysis had not been undertaken for each member of staff. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 32 35 38 The Registered Manager has a good knowledge of working within her job role and this ensures that a good standard of service is provided at the home. The system for the management of residents’ personal allowances is generally robust. Action was required in respect of a number of health and safety issues at the home in order to provide a safe environment for the residents to live. EVIDENCE: The Registered Manager is working towards the Registered Managers Award which is to be achieved by the end of 2005, and has had many years of experience in working with older people in a care home setting. A residents meeting had been held recently and the minutes of this was available. The home had a facility to hold small amounts of residents’ money for safekeeping and the system for the management of this was generally robust. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 18 The Registered Manager stated that audits in respect of this are undertaken regularly however a written record of this was not available and not all of the monies sampled by the Inspector were accurate. The home had failed to inform The Commission that a resident had sustained an injury following a fall as per Regulation 37 notification, however other accident records were found to be fully detailed and well maintained. Monthly audits of accidents are undertaken. Health and safety checks in respect of the fire alarm system, portable electrical appliances and other equipment used at the home were maintained as required, with the exception of the hot water outlets. The temperature of the water from a number of hot water outlets that the residents had access to were found to exceed the maximum safe temperature of 43 degrees centigrade and these had not been monitored for the past two months. Risk assessments had been undertaken in respect of the premises and grounds. Staff had received training in safe working practices including moving and handling, first aid, fire safety and health and safety. A fire drill had been undertaken recently. There were a number of outstanding requirements to be addressed following the recent Fire Officer’s inspection. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 2 4 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 2 COMPLAINTS AND PROTECTION x 2 2 x x 2 2 2 STAFFING Standard No Score 27 3 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 2 3 x x 2 x x 2 Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(a) Requirement Timescale for action 26 July 2005 2. OP7 15(1)(2) The pre admission document must be completed in full and be further developed to include the persons weight, history of falls, carer and family involvement and other social contacts/relationships. 26 August The care planning system must 2005 be further developed: Care plans must be written for each resident detailing how their care needs are to be met and this must include their health, personal, social care needs and their preferences. Care plans must be reviewed and updated monthly to reflect the residents changing needs. Care plans must be written and reviewed with the involvement of the resident and/or their representative. The daily report must include detail of the activiites that the resident had engaged in that day. The Registered Manager received this in the form of an immediate requirement. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 21 3. OP7 OP38 13(4)(b)( 5) 4. 5. 6. OP8 OP8 OP9 12(1)(a) 12(1)(a) 13(2) (4) (timescale of 31 March 2005 not met) Moving and handling and other personal risk assessments must be completed in full and updated regularly to identify the residents current abilities and must include detail of the action to be taken should a resident fall. Residents acute health care needs must be monitored. Residents must be weighed regularly. All medication must be labelled for individual use. All medication must be stored securely and this includes the location of the medication trolleys when not in use. 01 July 2005 01 June 2005 01 June 2005 26 April 2005 7. OP9 13(2) The Registered Manager received this in the form of an immediate requirement. All medication must be auditable. 30 June The medication policy must be 2005 reviewed to reflect changes in procedures. The requirements above were not assessed on this occasion. A lockable storage facility must be available in each residents bedroom. Risk assessments must be undertaken to identify the reasons why a number of residents do not hold the key to their bedroom doors and a record of this must be kept. A record of residents personal property into and out of the home must be kept and personal property must be stored appropriately. The Registered Manager must undertake a review of the serving of the food at mealtimes. 8. 9. OP10 OP10 23(2)(m) 12(4)(a) 31 July 2005 30 June 2005 10. OP24 23(2)(m) 01 June 2005 11. OP15 12(2) 01 July 2005 Page 22 Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 12. OP20 23(2)(g) The registered Manager must continue to review dining seating arrangements so that all residents wishing to be served their meals in the dining room are accommodated. (timescale of 31 March 2005 not met) 31 July 2005 13. OP21 23(2)(j) The Registered Provider must ensure that there are suitable working assisted bathing facilities within the home. An action plan is to be submitted to CSCI by: (timescale of 31 March 2005 not met) Curtains in residents bedrooms must be clean and in a good state of repair. Guards must be fitted to radiators in residents bedrooms. 30 June 2005 14. 15. OP24 OP25 16(2)(c ) 13(4)(a) 30 June 2005 31 August 2005 16. OP25 23(2)(p) The Registered Manager received this in the form of an immediate requirement The lighting in the residents en 26 April suite facilities must be in 2005 working order. The Registered Manager received this in the form of an immediate requirement All areas of the home must be hygienically clean and hygienic hand washing facilities must be available. Staff files must contain all information as required by Regulations. This requirement was not assessed on this occasion. The Registered Manager must undertake a training needs 17. OP26 13(3) 16(2)(j) 19(1) Schedule 2 27 April 2005 31 May 2005 18. OP29 19. OP30 18(1)(c )(i) 30 June 2005 Page 23 Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 20. OP37 37 21. OP38 13(4) analysis for each member of staff to identify their individual training needs. The home must inform CSCI of any accidents or incidents that affects the health or welfare of residents as per Regulation 37 notification. The temperature of water from all hot water outlets that the residents have access to must be checked weekly to ensure that the temperature does not exceed 43 degrees centigrade. The Registered Manager received this in the form of an immediate requirement The Registered Manager must submit a plan of remedial action to be taken following the recent Fire Officers visit. The Registered Manager must obtain a management qualification, i.e Registered Managers award / NVQ 4 in Care Management by 2005 26 April 2005 29 April 2005 22. OP38 23(4) 01 June 2005 31 December 2005 23. OP31 9(2)(b)(i) 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 OP35 Good Practice Recommendations It is recommended that the receipts of all personal items purchased by residents are numbered for ease of auditing and a written record of audits undertaken is kept. Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Willow Grange E54 S44889 Willow Grange V223341 260405 Stage 4.doc Version 1.30 Page 25 - 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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