Inspection on 29/11/06 for Bury Metro - Woodbury

This inspection was carried out on 29th November 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bury Metro - Woodbury 30/07/07

Bury Metro - Woodbury 20/01/06

Bury Metro - Woodbury 11/07/05

Bury Metro - Woodbury 21/01/05

Bury Metro - Woodbury 16/07/04

Bury Metro - Woodbury 11/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Bury Metro - Woodbury Woodbury Wesley Street Tottington Bury Lancs BL8 3NN Lead Inspector Julie Bodell Unannounced Inspection 29th November 2006 09:30 Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 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 Bury Metro - Woodbury DS0000053090.V297754.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 Adults 18-65. 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. Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bury Metro - Woodbury Address 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) Woodbury Wesley Street Tottington Bury Lancs BL8 3NN 01204 887424 Bury M.B.C. Mr Peter Miller Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 20th January 2006 Date of last inspection Brief Description of the Service: Woodbury is a Local Authority home providing care and support for adults who have a learning disability. The home provides three different services within one building. The semiindependent unit and the resettlement unit are registered as domiciliary care provision, and were not included in this inspection, which covered the four place short stay unit, and the emergency place. The short stay unit is on the ground floor. It is separate from the rest of the building and has its own entrance. The unit has exclusive use of a small lounge, dining kitchen, bathroom, and toilet. All bedrooms are single. Service users who are admitted in an emergency have use of a single bedroom on the first floor. They have use of the communal facilities used by those living in the resettlement unit. All service users are able to use the enclosed garden, and the relaxation room. The home is situated in the centre of Tottington, close to bus routes, shops, library, and other local amenities. Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took 5 hours alongside the inspection of Woodbury Accommodation Domiciliary Care Agency. Most of this time was spent watching what went on in the home, talking to 2 of the 3 service users who were staying in the short stay unit and 1 service user from the other side of the premises. The inspector spoke to 2 residential care officers who regularly work in the short stay unit, a senior residential care officer and the deputy manager. The inspector also looked round the home and examined some key records. The emergency bed was not in use at the time of this inspection. What the service does well: What has improved since the last inspection? Support workers have received training in administering medication. In order to promote the welfare of service users support workers are receiving training in the local authority vulnerable adult protection procedures. This will ensure that support workers know what to do should they become aware of an allegation of abuse. Seven new staff members have been recruited and appointed and will start work once the necessary checks have been undertaken. This means more support will be available to service users to be supported to be involved in outside activities. Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 6 There are plans in place to refurbish the bedrooms in January 2007. This will involve blocking off bedroom doors that allow access to the lounge and dining kitchen areas, which will improve privacy and create space and replace the built in wardrobes and the sink units. 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. The summary of this inspection report can be made available in other formats on request. Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users needs are assessed prior to an admission being agreed to ensure that there needs and aspirations can be met. EVIDENCE: Two of the service users personal files were looked at. They showed that community care assessments had been carried out by a qualified social worker and obtained before a respite place was offered to ensure that the service was able to meet the needs of the service user. Following completion of an application form to use the service, the home then carries out a more detailed assessment, in conjunction with service users and relatives, to ensure suitability and compatibility for all concerned, and to make sure that the admission criteria was met. The assessments were written from the service user’s perspective, and included the person’s likes and dislikes, how they liked to spend their time, and how they would like staff to assist them, with needs and wishes clearly recorded. There are generally four service users using the short stay facility at the weekends and two or three during the week. Arrangements are made on the basis of levels of need and compatibility. Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user plans were in place and these are updated to reflect any changes in their needs and goals. The home encourages service users to be as independent as possible. EVIDENCE: Both personal files that were looked at contained very detailed care plans that gave explicit guidance to staff members about how each person was to be supported. The care plans had been developed from the information gathered during the assessment and covered areas such as medication, mobility, communication, health care issues, dietary needs, personal hygiene, activities etc. Care plans included each service user’s preferences and goals, and reflected the home’s objective of encouraging service users to be as independent as possible and this was observed throughout the inspection. Service users, or their relatives, had signed their agreement to the care plans. Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 10 Records showed that the care plans were reviewed annually. Discussions with staff members about the service users were consistent with the service users’ care plan of how they were to support them. Service users who use the short stay unit or emergency place live at Woodbury for short periods only. Any major decisions about their lives would therefore tend to be made with their families or other representatives. Two of the three service users who were able to speak with the inspector said that they enjoyed coming to Woodbury very much. They said it was “brilliant” and it gave them an opportunity to be independent from their families but they also looked forward to going home. They were able to make decisions about their daily routine like getting up and going to bed and were also able to go to the day centre or outreach. Both service users came to Woodbury usually at the same time so they new each other well. They also liked the fact that they always had the same room. They liked all the staff team who were friendly and treated them well. Records showed that potential risks had been assessed, and balanced against the resident’s right to choice and independence. Risk assessments covered areas such as use of the kitchen, bathing, maintaining health, moving and handling, epilepsy, and general health and safety. Records showed that risk assessments had been agreed and signed by the service user or their relative. Daily report records were completed for each person. They included details of meals eaten, activities undertaken, and other general information related to the person’s needs. At the end of each service user’s stay at Woodbury, the home sent relatives a written summary of the visit. Four relatives provided their views about the home in writing. All but one said that they were satisfied with the overall care provided. Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst staying at Woodbury, service users are able to carry on with their usual weekday routines. During evenings and weekends, service users’ are able to pursue their chosen indoor leisure activities but opportunities for outside activities have to be pre-arranged for service users needing support. EVIDENCE: Discussion with service users and support workers showed that Woodbury worked closely with day services and colleges to ensure that during their stay at the Home service users were able to continue to attend their usual weekday activities. Service users said that they enjoyed pastimes such as watching television or films, listening to music, and knitting. They also enjoyed talking to staff. Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 12 Individual daily records include details of the activities undertaken. At previous inspections concerns have been raised at the lack of availability of staffing for service users to go on outside activities for those requiring support. Outside activities have to be planned in advance and cannot always be arranged spontaneously. The deputy manager felt that this situation would improve soon with the recent recruitment of seven support workers, which will increase hours by twenty percent across the service. This situation will be assessed again at the next inspection. Service users said that nobody entered their bedrooms without knocking. Locks were fitted to bedroom doors, and service users said that they could have a key if they wanted to. A good rapport was observed between the support workers and service users and the atmosphere was relaxed and friendly. Service users said that they liked all the staff team at Woodbury. Relatives and friends are able to visit service users during their stay at Woodbury. Some service users liked to maintain contact by telephone. Service users have there own small kitchen/dining room. There are facilities to make drinks and small meals like breakfast and snacks. The main meal of the day is made in Woodbury’s main kitchen. Service users said that they enjoyed their meals and that they got enough to eat. There is a list of dietary needs for short stay users that identifies allergies, problems, dislikes and how the service user is to be supported. The inspector joined service users for breakfast. Service users were encouraged to make their own breakfast. Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal care in a discreet manner. The home liaises with families to ensure that health needs are met. The medication system and procedures are generally satisfactory. EVIDENCE: Service users said that they took care of there own personal care needs with help from support workers if they needed it. Support workers were observed to assist people in a discreet manner, e.g. ensuring that doors were kept closed. Families generally took responsibility for making health care appointments. Support workers monitor service users health during their stay. If there was a cause for concern then service users family would be contacted, or they might contact the GP, BARDOC, NHS Direct, or to hospital if necessary. In July 2005, the Pharmacist Inspector visited the home to look at medication procedures. The deputy manager said that all staff members had received Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 14 medication training. The medication system was generally in good order. Photographs identifying service users need to be in place to ensure that medication is administered to the correct person. The local authority medication policy and procedure has recently been revised and approved. Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a written complaints procedure. Service users felt that they could raise any concerns and that they would be listened to and dealt with. The training of the staff team in adult protection procedures is ongoing. EVIDENCE: The home has a written complaints procedure, which is available to service users. However two of the relatives who provided written comments said that they were not aware of the procedures. Service users said that that they knew who to speak to if they had any concerns and were comfortable about raising issues. The home had written procedures covering Adult Protection and Whistle Blowing. The subject also forms part of the Learning Disability Award Framework training. A senior residential care officer has attended a trainer’s training course to enable her to train other staff in protection. The inspector was informed that this training is ongoing and most staff members have either completed the course or the training has a planned date. The inspector is satisfied that this matter will be completed in the near future as part of mandatory training. A requirement has therefore not been made. Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ongoing efforts have been made by the home to make the short stay unit safe, homely and comfortable for those who use the service. The general appearance of the home has also improved. EVIDENCE: The home is situated in the centre of Tottington, close to bus routes, shops, and other local amenities. The short stay unit is on the ground floor. It is separate from the rest of the building, and has its own entrance. The unit has exclusive use of a lounge, dining kitchen, bathroom and toilet. All bedrooms are single. Any service user admitted in an emergency has a single bedroom on the first floor. They also have use of the communal facilities used by those living in the resettlement unit. The enclosed garden provides a pleasant setting where people can sit out in nice weather. Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 17 Ongoing efforts have been made by the home to make the short stay unit safe, homely and comfortable and the general appearance has improved. New fire doors have been fitted throughout the Home. Bedrooms were individually decorated in different colour schemes, and service users brought in a few of their own possessions to make their rooms more homely. Plans are now in place to refurbish the bedrooms and replace wardrobes, drawers and vanity units, which look tired. Work is scheduled to take place in January 2007. The requirement for this work to be carried out has been removed on the basis that the plans are in place. The situation will be assessed again at the next inspection. The home is fitted with adaptations and equipment suited to the needs of the service users. These included grab rails, portable hoists, assisted bath, shower, ramps and assistance call system. Keypads were placed at entrances to the short stay unit to aid security. Bedroom doors were fitted with alarms. There was no passenger lift, so anyone using the emergency bedroom would need to be able to use the stairs. Standards of cleanliness in the short stay unit were good. Liquid soap and paper towels were provided for hand washing in communal areas. Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are currently stretched across the four areas of service provided at Woodbury. New support workers have been recruited and this should improve the situation. The standard for achieving NVQ targets has not been met. EVIDENCE: It was observed that service users had no hesitation in approaching staff members if they needed them. Service users said that they would go and see the manager or a staff member if they needed to talk about anything. Only eight of the support workers had completed NVQ training with a further three currently undertaking the course. This does not represent 50 of the staff team. Involvement in NVQ training needs to continue to be encouraged with a view to having at least 50 of workers with the qualification. Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 19 The short stay unit has a senior and four support workers. During each shift, a designated worker is assigned solely to the short stay unit. A second support worker who divides their time between the short stay unit and the semiindependent unit assists this worker at peak times. Out of the four relative survey responses returned three where of the opinion that there not always sufficient numbers of staff on duty. There are also gender issues around intimate care that may prompt a change to the identified above in this case a male key support worker and three female service users. It was noted that a staff member stayed in situ at all times with the service users on short stay. However, during periods of this inspection, there were only three members of staff on duty to a total of thirteen service users, stretched across the three service areas within Woodbury. This also included managing a situation that had been ongoing between two service users’, from another part of the service that needed to be supported separately to ensure safety and minimise risk whilst the issue was resolved. One of the service user’s was therefore spending periods of time on the short stay unit. Staff members said that it had been a difficult year with only 3 – 4 staff members on duty rather than 5 – 6. This was confirmed on examination of the rota. The inspector was informed that 7 support workers four full time and three part-time had been appointed and will start as soon as their CRB checks are returned and they have medical clearance. This will see a weekly increase of 133 hours in total, which represents a 20 increase in staffing. It is expected that these people will be in post early in the New Year. A care pool team of five people has been created, which has proved essential and means the service now rarely uses agency staff cover. The managers’ felt that after many years of staffing problems the future was looking promising. This will give support workers more opportunity to do individual support with service users. A new senior staff member is also due to start in the New Year, following induction training. In addition to care staff, the home employs a cook, an administrator, a maintenance worker, and a domestic worker. Agreement has been reached to employ a second cook. Following the last inspection the inspector requested that a list of mandatory training that had been undertaken be produced. This has been done and shows that 85 of the mandatory training needed to be undertaken by the staff team has been completed and places for outstanding training are booked to take place in the following two months. Three support workers are undertaking a counselling course and a senior staff member is on the final year of Diploma in Social Work. Computer training for support workers is also being looked at as more information is starting to be held on electronically. Two inspectors for CSCI sometime ago carried out examination of recruitment information held by the local authority. A number of issues where raised that have now been rectified. Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 20 Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home and they are able to openly express their wishes. Service users and others are asked for their views on the quality of the service EVIDENCE: The manager is registered with the CSCI. He has been manager of Woodbury since 1992. He holds the Certificate in Social Service qualification and the Registered Manager’s Award. From discussion, it was evident that the manager encouraged an open, inclusive atmosphere within the home. The hours the manager work must be recorded on the rota. Service users said that they found the manager and senior staff to be approachable. Staff members Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 22 felt that the home was generally well run despite the fact that there were sometimes staffing shortages. Quality Assurance checks were carried out with a record of visit and comments being requested from service users about whether they enjoyed their stay at Woodbury. A telephone call was made to the family on return and a record of their comments kept. A relative comment card stated that feedback had improved recently but did not always happen. Information needs to be fed into a review of the quality of care and a report produced a copy of which needs to be sent to CSCI. Managers’ spoken with felt that Woodbury was getting better at quality assurance monitoring. Maintenance and service checks were examined. These included clinical waste, emergency lighting, portable electrical appliances, gas, hoists and assisted baths. The certificate for the Home’s electrical fittings and fitments, NEICIC, was dated 01.03.01 and valid for 5 years. A new certificate needs to be obtained as soon as possible to ensure the health and safety of service users and the staff team. Bury Metro - Woodbury DS0000053090.V297754.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 X Bury Metro - Woodbury DS0000053090.V297754.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 YA20 Regulation 13 Requirement That a photograph of the service user is available with the MAR sheet to ensure that medication is administered to the correct service user. That service users families or representatives are given a copy of the complaints procedure where appropriate. The registered person needs to continue to encourage and support staff members with NVQ training with a view to having at least 50 of workers with the qualification. (Outstanding) Staffing levels, and the deployment of staff in the short stay unit, need to be sufficient to enable staff members to offer flexible support to service users. (Outstanding) The hours worked by the registered manager must be recorded on the rota. That a review of the quality of care is undertaken, a report produce and a copy forwarded to CSCI. That a copy of a valid NEICIC certificate is forwarded to CSCI DS0000053090.V297754.R01.S.doc Timescale for action 31/01/07 2. YA22 22 31/01/07 3. YA32 18 31/03/07 4. YA33 YA13 18 31/01/07 5. 6. YA37 YA39 17 24 31/01/07 31/03/07 7. YA42 23 31/03/07 Bury Metro - Woodbury Version 5.2 Page 25 in respect of the safety of the Home’s electrical fitment and fittings. This check is overdue. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bury Metro - Woodbury DS0000053090.V297754.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Bury Metro - Woodbury DS0000053090.V297754.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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