Inspection on 05/07/06 for Yardley Grange Nursing Home

This inspection was carried out on 5th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Yardley Grange Nursing Home 17/11/08

Yardley Grange Nursing Home 03/07/07

Yardley Grange Nursing Home 19/10/05

Yardley Grange Nursing Home 01/06/05

Yardley Grange Nursing Home 12/10/04

Yardley Grange Nursing Home 29/04/04

Yardley Grange Nursing Home 14/01/04

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

CARE HOMES FOR OLDER PEOPLE Yardley Grange Nursing Home 465 Church Road Yardley Birmingham West Midlands B33 8PA Lead Inspector Karen Thompson Unannounced Inspection 5th July 2006 09:30 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 Yardley Grange Nursing Home DS0000024912.V302119.R02.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. Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Yardley Grange Nursing Home Address 465 Church Road Yardley Birmingham West Midlands B33 8PA 0121 789 7188 0121 789 5819 joanna.king@yardley.great.trust.org.uk 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) Yardley Great Trust Ms Joanna King Care Home 45 Category(ies) of Dementia (45), Dementia - over 65 years of age registration, with number (45), Old age, not falling within any other of places category (45), Terminally ill (45), Terminally ill over 65 years of age (45) Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. Up to 20 people receiving continuing care within usual staffing levels (see conditions 5 & 6) Between 7 & 10 people receiving continuing care support with 1 additional carer on duty throughout waking day The Manager to be supernumerary to registered nurses Two registered nurses will be on duty at all times, day and night In addition to registered nurses there will be 8 care staff on duty each morning, 8 each afternoon, 4 after 8pm, and 3 on duty all night That the manager successfully undertakes the Registered Managers Award or equivalent by April 2005. (Condition met will be removed from certificate and a new certificate issued) Service users over the age of 60 at the date of admission can be cared for in this home One named service user under 60 years at the date of admission can be cared for in this home. (The Service User is no longer accommodated at the home, this condition will be removed and a new certificate will be issued.) 19th October 2005 Date of last inspection Brief Description of the Service: Yardley Grange Nursing Home was relocated to purpose built premises during the summer of 2002. It is situated in a quiet road in a suburb of Birmingham within easy reach of public transport. The building stands within picturesque grounds with mature trees and there is sufficient off road parking with an attractive rear garden accessible to residents. The home provides twenty-four hour nursing care to forty-five people over sixty years of age who may have dementia or may be terminally ill. All rooms are single and have ensuites facilities and there are sufficient bathrooms, shower rooms and toilets to meet residents’ needs. Communal space includes a lounge and pleasant dining rooms on both the ground and first floor of the premises. There are a range of aids and adaptations designed to assist in the management of residents with restricted mobility. Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The findings of this report are following a statutory unannounced inspection. The inspection was carried out over two days by one inspector. Information for the report was gathered from a number of sources: a tour of the building, examination of records and documents, talking to residents and staff members and direct and indirect observation. What the service does well: What has improved since the last inspection? The Service Users Guide and Statement of Purpose have been updated ensuring residents are fully informed of what facilities and services the home can offer. Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 6 The Registration certificate is full displayed so residents and relatives are aware of what the CSCI expects to be in place in relation to the running of the home. Staff recruitment procedures are robust, ensuring that residents’ are protected. The Care Manager has completed a recognised qualification in care thus consolidating their experience and knowledge for the benefit of residents’. 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. Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 Quality in this outcome is adequate. The judgement has been made using available evidence including a visit to this service. Information to residents is up to date and reflects changes in the home ensuring that the residents’ are fully informed. Systems in place for preadmission assessments are good, ensuring that residents do not move into the home unless these needs can be met. Not all residents had a contract. Care plans did not always recognise the strengths of residents with cognitive impairment thus omitting the potential empowerment carers could promote on behalf of residents’. EVIDENCE: The Statement of Purpose and Service Users Guide have been amended recently and a copy of these documents was given to the inspector. The amended documents will need to be distributed to residents. The Service Users guide contained quotes from the previous inspection report. Permission is required to quotes extracts from any CSCI report and this had not been sought. Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 9 Not all the residents’ files examined contained a copy of the contract. The contract seen in one of the residents’ files met the standard and was user friendly. The Care Manager or deputy carry out pre admission assessments and these meet the standard. Individual details were recorded on these pre admission assessments and there was good evidence of recording residents’ choices, preferences and wishes and of these being implemented when the resident was living in the home. The home accepts residents with dementia. Some staff have received training in dementia awareness. Care plans did not demonstrate how residents with dementia would have their specific needs met in relation to this condition. Care planning needs not just to focus on difficulties but strengths and abilities and how these can be utilised to the full. Confrontational behaviour was observed during the inspection and was dealt with by care staff in the appropriate manner. Approximately a third of care staff have receive training in dealing with challenging behaviour. More staff training is needed in this area so that all staff are aware of how to assess, monitor and respond appropriately to such difficult situations. This will ensure that staff are not just reacting to situations but have the skills to be proactive and limit or prevent such occurrences. Staff were observed to assisting residents with sensory impairment in the correct manner, anticipating needs and interacting appropriately. Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The quality of care planning for the majority of residents was good. There was evidence of good multidisciplinary working taking place on a regular basis but the home was not assessing all health needs and this could potentially lead to poor outcomes for residents. The arrangements for medication administration were variable leading to potentially poor outcomes for residents. EVIDENCE: A relative informed the inspector, that each resident had care planning documentation in his or her room. Staff need to formalize the involvement process of both residents and representatives by ensuring that they are active participants in drawing up these care plans and that they are signed by either or one of these. Four residents care plans were looked at during the inspection. These set out the action to be taken by care staff to ensure aspects of health, personal and social care needs of residents are met. There were good examples of individual detail in these plans. Not all care plans however were found to have Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 11 been updated to reflect changes in care being given. One resident was observed to have suction equipment in their room but this was not acknowledged as a possible care planning needs. Short-term conditions were also not being acknowledged in the care plans. Risk assessments for nutrition, skin integrity, falls, manual handling and bedside rails were in place. The format used for the bedrails risk assessment was confusing this was discussed with the Care Manager and the home is looking at reviewing this. Care plans did not contain any mental health or continence assessment. These assessments are important, as they are indicators of unmet need. Some trained staff have recently attended a tissue viability course. Staff spoken to stated that they had found this informative and useful. The Tissue viability service contacted the Commission post inspection and expressed concerns as they had recently been contacted by the home to see a resident. The documentation in relation to this residents care was poor the home was unable to demonstrate what assessments, treatment and strategies had been put in place was poor. The Commission contacted the Care Manager and has done an internal review and has put strategies and procedures in place to monitor the effectiveness of recordings. The inspector will monitor this at the next inspection. During the inspection the inspector observe a number of multi disciplinary health professionals visiting the home. Staff at the home were able to demonstrate a pro-active approach to meeting residents health needs. Staff appear to be doing routine blood glucose monitoring for resident on a regular basis. This practice needs to review with the GP service. If a diabetic resident’s blood glucose levels are normally stable and there are no other causes for concern in relation to their health, these residents can be offered an Hba1 test by the GP practice. The home employs a physiotherapist who visits once a week and residents’ benefit from this service, which is to be commended. One relative commented in relation to changes in health “staff are kind, very good and report to family any changes they will inform on arriving at the home”. Not all medication was auditable. Schedule drugs that had been received into the home were not being stored appropriately. Regular staff drug audits are required to monitor and improve staff practice. There are a number of residents who have their medication via their PEG. The home needs to ensure that medications given via this route are discussed with the company manufacturing the drug to ascertain best practice. The home must keep a written copy of its discussion with the medical information department with the residents’ records. Copies of the original prescriptions were available. Staff need to ensure that if they handwrite a prescription on the MAR chart that there are two staff signatures alongside this as proof of checking. A number of residents in the home receive oxygen and there were guidelines in place for the administration of oxygen. The medication rooms were hot and staff need to monitor the temperatures of these rooms and keep records. If the medication rooms exceed 25c them the home needs to review how this can be Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 12 reduced. This was discussed during the inspection. The Care Manager was talking to engineers about how to reduce temperatures in the bathrooms as these were excessive for both staff and residents during the hot weather and stated the home would also review temperatures in medication rooms. Residents were observed to be appropriately dressed and their clothes were nicely laundered. Staff were observed knocking on residents rooms prior to entering them. Phone calls can be made or received in private via three methods employed within the home: a phone installed in a residents room, a call box available the hospitality lounge and a hand held phone which can be given to residents to make or receive a call. Care of the dying was not fully inspected at this inspection but trained staff have received training in verification of death, approximately half the care staff have received some training in care of the dying. Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. The judgement was made using available evidence including a visit to the service. Residents’ independence and choice is maintained through a variety of systems within the home. EVIDENCE: The home employs an activities co-ordinator and a variety of activities from the records held could be seen to be taking place. The home had recently celebrated its annual party to commemorate its opening. Twelve residents had also attended a fete held at another home within the organization. The activities financial records were not inspected on this occasion, as they were not in the home at the time of the visit. These records will be reviewed at the next inspection. Visitors are welcomed to the home. The exceptions to visitors not being permitted in the home are clearly laid out in the residents contract and they are not being permitted in the dining room during meal times. Visitors however can have a meal at the home in the residents’ bedroom for a nominal fee. Residents’ bedrooms were personalized with their own possessions. Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 14 The inspector had a meal with residents that was nicely presented in a pleasant environment. Staff assisted residents discreetly and sensitively. Residents can choose where they wish to take their meal. The home was in the process of reviewing menus. One resident stated “food not bad at all” they also went on to state they were given a choice from the menu. Residents are asked a few hours before their next meal what they would like, which is positive as it ensure flexibility and choice is maintained. The catering staff have reviewed the presentation of pureed meals and are in the process of testing moulds specifically designed for pureed portions. This is a positive move and can only be of ultimate benefit to residents’. Fresh fruit and vegetables were observed in the Kitchen. This reflects the use of seasonal products that bring variety into the diet and varying food textures. Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Complaints and Adult protection matters are dealt with in a professional, sensitive and robust manner EVIDENCE: During the visit concerns that had been raised by an external health care agency were discussed with the Care Manager. The home had good documentary evidence to support the findings that they had not breached any standards or regulations. The home has received four complaints since its previous inspection and they have been dealt with in a professional and sensitive manner. During the inspection the inspector was shown an adult protection policy and procedure that did not meet the standard. A copy of the revised adult protection policy and procedure was forwarded to the Commission following the inspection and this meet the standard Approximately 80 of staff have received training in adult protection. The home needs to review when training will occur for the rest of the care staff and ensure that trained staff are also familiar with adult protection issues and the policies and procedures to follow. Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-maintained homely environment, which promotes their well being. EVIDENCE: The home is on two floors with bedrooms and communal areas on each floor. The home was clean and odour free. One of the downstairs communal areas had recently been redecorated with residents being involved in the choosing of the wallpaper in this area. There is an enclosed garden at the back of the home where residents and visitors can sit. There are plans to extend the patio area to increase accessibility for residents into the garden. The home has a number of assisted bathing facilities around the home. One of these was not working and the home is awaiting new parts for the bath. One bathroom had a domestic type bath in place and this has led to the room being used for storage purpose. The home should consult with an occupational Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 17 therapist as to the best use of this facility. Whilst residents on this particular wing have access to bathing facilities, distances travelled will impact on their privacy and dignity. Also at the time of the inspection one of the assisted bathing facilities were not working thus facilities for bathing were further reduced. All bedrooms are single with ensuites facilities. Bedrooms were individualized with residents’ own personal possessions. Overall the home has good systems in place to minimize cross infection. The laundry has a dirty in and cleans out system. Alginate bags are used for soiled linen. Sluices were not locked and a number of COSHH items were accessible to residents. The sluices have been well designed but on the day of the inspection the hot air hand dryer in one of these sluices was found not to be working. No other means of drying one’s hands was available in this sluice area. Gloves and aprons were freely available for staff to use. Bars of soap were found in some bathroom areas and the Care Manager removed these. Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Agreed staffing levels are being maintained. Recruitment procedures have improved with only one area of weakness identified. EVIDENCE: Two-week rotas were supplied to the inspector for all staff working in the home. In April the home increased the number of residents who could be admitted to the home under the continuing care criteria. Residents meeting minutes indicate resident may have to wait for a carer to assist them to bed after eight o’clock in the evening. Figures supplied by the home suggest a high percentage of staff have completed or are in the process of completing an NVQ 2 in Care. It is recommended that the Care Manager looks at the NVQ2 course available especially in dementia care for some of the staff as they have a significant number of residents with cognitive impairment. Staff files were sampled and the majority met the standard. There were four staff files where a portable CRB had been accepted and the home had not submitted a CRB disclosure for these staff members on commencing work at the home. Homes cannot longer accept portable CRBs but in exceptional circumstance they can employ someone after first submitting a POVA first enquiry. The home was found to be making application under the POVA first Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 19 system. Also the CRB disclosures submitted for a few members of staff were found not to contain middle names, it vital that all names are submitted for the check to be comprehensive. Staff spoken to during the inspection were positive about the training provided by the home and were able to demonstrate how it impacted on the care they gave to residents. An induction programme is in place for all new staff which is linked to the Skills Council. A training matrix was given to the inspector and some areas of mandatory training have elapsed. The home needs to audit these shortfalls and ensure staff receive this training. Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. The management team ensure that the home is run and managed for benefit of the residents. There are robust systems in place for managing residents’ finances. Health and safety is well managed in the home with only minor areas that need improvement. Staff supervision needs further development to ensure that staff are supported and able to fulfil their role of delivering care to residents. EVIDENCE: The Care Manager has considerable experience in working in a care setting and has recently completed a qualification in management. Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 21 Good interaction was observed between residents, relatives and staff. There are regular resident and staff meetings. The providers’ representative visits monthly and produces a report. The home has employed an external quality assurance organization to help them with meeting this standard. The home sends out questionnaires to residents to review the service it is providing. These will be looked at during the next inspection. Residents’ finances are kept in a safe place. Each resident has an individual transaction sheet and with receipts so that expenditure can be audited. Supervision was taking place but record keeping was poor in relation to what the supervision covered. A number of certificates for maintenance and servicing could not be located during the inspection. The home forwarded these after the inspection. Health and safety matters on the whole were well managed. The frequency of hot water testing needs to be increased in all areas that residents have access to. Baths and showers should be tested weekly, as there is a higher risk of total immersion in these areas and potential for scalding. Legionella disinfection was carried out on 10 July. Evidence that this procedure had been effective was not available at the time of writing the report. Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 2 3 3 3 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 X 2 Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5 Sch4 Requirement The Registered Person must ensure that all residents have a contract on the point of admission to the home. The Registered Person shall ensure that care plans are fully reflective of residents’ current and changing care needs. Plans should be reviewed and evaluated at least monthly. (Previous timescale 02/05 & 10/05 not met) The Registered Person must ensure that residents’ with cognitive impairment have their needs planned for and this includes acknowledgement of residents’ strengths and abilities. Timescale for action 30/08/06 2 OP7 OP4 15(1)(2,b) 17(1a)(3k) 30/09/06 Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 24 3 OP8 12(1) The Registered Person must ensure that residents have a mental health and continence assessment. From this a plan of care must be devised to meet recognised needs. 30/09/06 4 OP9 13(2) The Registered Person must ensure that assessments in relation to skin integrity are in place and following this assessment, treatment and strategies are put in place to met needs. 30/08/06 Temperatures in the downstairs clinical room must be recorded to ensure that medicines are stored in compliance with their product licences to maintain their stability. (Outstanding requirement 10/05) Staff drug audits must be undertaken on a regular basis to confirm nursing staff competence in medicine management and appropriate action must be taken when discrepancies are found. (Outstanding requirement 10/05) The Registered Person must ensure that all medication is auditable. The Registered Person must contact each drug manufactures’ medical information service in relation to medication administered via PEG tubing and seek advise as to safety and compatibility. A record of this conversation must be kept on the residents file. Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 25 5 OP26 13(4) 6 OP30 18(1)(c) 7 OP36 18(1)(c) 8 OP38 13(4)(a-c) The Registered Person must ensure that sufficient hand washing are working or an alternative is available. The Registered Person must ensure that all bars of soap are returned to residents’ rooms after use. The Registered Person must audit all mandatory training and any deficits in staff must rectified. The Registered Person must ensure that all staff receives formal supervision six times a year and that this is formally documented. The Registered Person shall ensure that water temperatures are tested more frequently in areas of high risk for example baths and showers. (Outstanding requirement 10/05) The Registered Person must ensure that Sluice doors are locked so residents cannot access and COSHH items are not accessible. 30/08/06 30/10/06 30/10/06 30/08/06 Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 26 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 OP29 OP7 Good Practice Recommendations All bank staff files are regularly updated in particular the employment record of the bank employee. (Carried forward, not inspected on this occasion) It was recommended that short-term care plans be devised and implemented for those residents admitted to the home under the category of continuing care beds. (Carried forward not inspected on this occasion) The Registered Person consults with an occupational therapist how the domestic bath can be made accessible to residents. The Registered Person discusses with the GP service the introduction of Hba1 testing for diabetic residents. The Registered Person must seek permission from the CSCI to print extracts from its report. 3 4 5 OP21 OP8 OP1 Yardley Grange Nursing Home DS0000024912.V302119.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham 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. 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