Inspection on 30/11/06 for Foxwood

This inspection was carried out on 30th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

CARE HOME ADULTS 18-65 Foxwood 5 Mill Lane Wolverley Kidderminster Worcestershire DY11 5TR Lead Inspector Dianne Thompson Unannounced Inspection 30th November 2006 13:45 Foxwood DS0000066844.V320337.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 Foxwood DS0000066844.V320337.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. Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Foxwood Address 5 Mill Lane Wolverley Kidderminster Worcestershire DY11 5TR 01562 852965 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) www.dimensions-uk.org Dimensions (UK) Ltd Mrs Lesley Anne Goodwin Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 06.03.06 Brief Description of the Service: Foxwood is a traditional two storey detached house in a secluded location in a residential area of Wolverley. The bedrooms are individually decorated and furnished. There is a shared lounge, dining area and kitchen. Local shops and access to public transport are nearby, whilst the home has its own vehicle for service users to use locally. The home aims to provide a domestic environment promoting independence and dignity. Service users receive care and support to live as ordinary a life as possible in the community. This involves staff teaching skills and creating opportunities on behalf of individual service users. Service users are encouraged to participate in the running of the home and share in general household activities within their capabilities. The registered manager is Lesley Goodwin. Dimensions (UK) Ltd is now the care provider for the service, having registered with the Commission for Social Care Inspection on 1st April 2006. The current fee for the service range from £392.00 per week. Charges which are additional to the fee include: • • • • • Personal toiletries, clothing and electrical items such as TV and music centre. Activities not covered by the allowance made by the provider or in the funding authority contract Holidays Major extra outings Hairdressing Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that included an unannounced visit to Foxwood. This was the home’s first inspection since Dimensions (UK) Ltd registered as the care provider. The main purpose of this inspection was to assess the service provided against key National Minimum Standards. Service user and staff records were examined, and a tour of the building was also carried out. Accumulated evidence from reports of monthly visits by the provider’s representative was used to inform this report. Time was spent with the assistant manager, service users and staff on duty. Three service users were at home at the time of the inspection visit and another service user was attending a local day centre. What the service does well: The home gives clear information to service users about the home. Before someone new moves into the home staff check that they will be able to give them the care they need. The home looks after people well and writes down what help everyone needs. Service users are given help and support to do the activities they choose. Families and friends are welcome to visit the home. Service users can choose what they like to eat from the healthy menu at the home. Service users are supported with their medical appointments and their health care. All staff are trained to give medication safely. Service users can talk to staff about any problems they may have. Staff are trained and know what to do if there are any problems. Foxwood is homely, clean and tidy. Service users can decorate their rooms in the way they like. Staff are well trained. The home checks staff before they start working in the home. Dimensions checks the home to make sure that everything is being done properly. They check to make sure the home is a safe place to live and work in. Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Foxwood DS0000066844.V320337.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 Foxwood DS0000066844.V320337.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): 1, 2, 3, 4 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides detailed information is provided about the services it offers to help service users choose to live at Foxwood and to see if the home can meet their needs. EVIDENCE: The home’s statement of purpose has provides up to date information about the home to help prospective service users decide if they wish to live at Foxwood. The service user guide has yet to be updated to include information about Dimensions, the new care provider. The homes assistant manager said that copies of the revised Statement of Purpose and Service User Guide would be accessible to all, including visitors to the home. All service users receive copies of relevant information prior to moving into the home, which is offered in preferred formats, such as symbols and pictures, audio and large print. There are no vacancies at the home, but an admissions policy and procedure is in place should a vacancy arise. The home’s assessment process is very Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 9 detailed and the manager and service users care records demonstrate that the home receives full information about prospective service users, their background, their needs, their likes and dislikes when they are referred for a placement. Information is gathered from a range of sources including other relevant professionals, visits to previous homes or schools, and discussions with family members. Introductory visits and stays are arranged at the home prior to admission. During the introduction to the home prospective service users are given a copy of the Statement of Purpose and Service User Guide. The home would benefit from administrative support to assist staff in updating essential information such as the Service User Guide. Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 10 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, 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plans provide staff with relevant information about users assessed needs. They include risk assessments that show how risks are to be reduced and independence promoted. Service users are helped to make choices and decisions in their daily lives and routines. EVIDENCE: Service user care plans are detailed and informative. The plans show how goals are monitored, how they are arranged and how they can be achieved. Staff have information to make sure that all care is provided in a preferred and consistent way that encourages independence. A person centred care plan (PCP) approach is being developed and this format shows how service users will be appropriately involved in planning and reviewing their own care. They will be supported to express their wishes and Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 11 goals. A Path map has been completed for the home and the service that is being provided. The Path map process has given staff knowledge and experience to support service users in completing their PCP’s. The training and completion of the home Path gives staff an opportunity to explore, share ideas and take responsibility for specific areas of work. Individual paths for service users have been started. An advocate is supporting one service user in their care review to help with planning for the future. Files for two service users were examined. Case tracking provides a view of how the home responds to the diversity of needs and how this is being managed and supported. This is particularly evident where health needs and disability requires greater input and support from all staff within the home. Relevant information and monitoring is provided in service user files to make sure all staff have the necessary information to provide quality care. Of the two files examined it is clear that information generally needs to be updated. The existing care plans provide information for the care and support for each service user. There is evidence that appropriate guidelines and goal planning includes professional and specialist support. Some information does need to be reviewed even if there are no changes to the support needed such as the communication information in one service users file. Each service user is allocated a key worker to oversee their care. Each key worker builds a closer relationship so they gain more understanding and knowledge of individual needs, goals and wishes. Staff sign to say they are fully aware of the plans and use them to guide their practice. The home completes risk assessments to promote safety and independence for service users. Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 12 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, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users receive help and encouragement to lead active and interesting lives and are supported to access facilities within the wider community. They are also supported to maintain links with their families and to develop friendships. The home offers a well-balanced menu and promotes healthy eating for the welfare of all service users. EVIDENCE: The home provides a range of activities for service users, both in-house and within the local community. All activities are organised to take into account Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 13 the individual needs and preferences, making sure that everyone has the opportunity to take part. Evidence was seen in service user files where a skills teaching index is used to encourage skill development. As a skill is achieved a new one is introduced. In one example objects of reference are being used. There are long and shortterm goals included in these plans, each providing staff and service users with clear guidelines to follow. Feedback instructions are also provided for staff for a consistent approach. All staff sign to say they understand and work to these guidelines. Examples where support has been provided to develop such skills is evident and includes shopping to choose a poster for a bedroom wall, and helping to recycle rubbish into the correct waste bins. Ideas and suggestions for activities are discussed in the weekly service users meetings and planned for the forthcoming week. Activities are encouraged and promoted both in house and within the local community. A weekly activity-planning sheet identifies various activities scheduled for the week and includes relaxation time and housekeeping tasks. This information is summarised monthly to provide a clear account of activities and lifestyles for all service users. Activities include going for a ride in the car, day trips, watching a DVD, shopping, going for a walk, feeding the horse, Snoezelen, and lunch out. Household tasks include service users taking their laundry to the laundry room and putting it into the washing machine, setting the table at meal times and assisting with cooking main meals. Evidence is available to show that regular contact with friends and family is supported. The home provides well-balanced meals, with drinks and snacks available at all times. Food offered is varied, healthy and appropriate to individual needs. Service users were observed being supported to make themselves a drink of their choosing during the inspection visit. One service user said that he was having pasta bake for tea that evening, and that he went for a meal to the pub with a member of staff the previous evening, and chose pie. Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 14 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, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Personal and healthcare needs are clearly identified in care plans. These plans provide information to promote consistency of care and support for all service users in a way that takes into account their preferences. The home has a clear medication policy and procedure, which is followed to make sure that all medication is administered and stored safely for the protection of service users and staff. EVIDENCE: Service users’ care records and plans provide detailed information about their physical and mental health and the support needed from staff to maintain their good hygiene and health. The care plans sampled contain information about service users preferred personal care routines. Health action plans include related risk assessments, such as pain management assessments. Parts of the health care plans would benefit from Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 15 retyping as changes and alterations to the information make it unclear, untidy and at risk of mistakes being made. The service users at home at the time of the visit were mostly unable to communicate, but they appeared to be comfortable and at home in their environment. Records of all physical checks are completed where service users have particular health related issues such as weight. In this way the home is able to closely monitor and respond to changes or obtain appropriate medical input whenever necessary. It is good practice to specify the frequency of weight checks to make sure these checks are carried out regularly and consistently. Service users and the home are well supported by medical services, which include GP’s, clinical psychologist, audiologist, community learning disability team, dietician and the intensive support team. Arrangements are in place for preventative health services, such as dental checks and annual health screening. Staff on duty said that all personal care is given in private to promote dignity for all service users. The assistant manager is very aware of the specialist services that could be needed to support service users and how to access them. This is further demonstrated within the management of service users health within the home. Researches into foods that are likely to affect the wellbeing of a service user are being monitored and evaluated. The assistant manager explained the system and demonstrated the effectiveness of the recording that had been completed. The dietician throughout this process provides advice and support. Evidence shows that by avoiding certain foods where intolerance has been identified, a reduction in medication and an improvement in service users health have been achieved. The home has a medication policy and procedure in place. Medicines are suitably and safely stored and there is appropriate storage for controlled drugs, should they be required. Information is available to advise staff about prescribed medication together with any possible side effects. A medication information fact sheet is provided both in individual files and in the medication file for each service user and gives details of all current prescribed medication. The assistant manager confirmed that the organisations policies and procedures would be followed should any medication error occur. Additionally these would be reported to CSCI. Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 16 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, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are protected by easy to understand information about how to complain, with appropriate information for staff provided. Staff support service users to express their views and any concerns they may have. EVIDENCE: The home’s complaints procedure is available in widget signs and symbols to make it accessible for service users. The assistant manager confirmed that there has been no complaints made to the home and no complaints have been made to the CSCI since the previous inspection. The home has relevant policies for service users’ protection. Policies and procedures are available which advise and guide staff in protecting service users. Staff were observed interacting with service users in a supportive and respectful way throughout the inspection visit. Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 17 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, 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Foxwood provides accommodation for service users that meets their needs and offers a safe, spacious and comfortable home, although the home needs redecorating. The home is kept clean which ensures that good hygiene and infection control is maintained for the benefit of service users. EVIDENCE: The inspection visit included a tour of the home. Foxwood is in a residential area of Wolverley. Foxwood is a traditional detached house with a shared lounge, kitchen, dining area in the conservatory, four bedrooms, one bathroom with toilet, one shower room, laundry, and office. The inspector was given a tour of the home, which included two service users bedrooms. Both rooms are individually decorated and furnished in ways that promote independence. Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 18 There is an enclosed rear garden and small front garden. The home has been scheduled for redecoration since the previous inspection. It is disappointing that this work has not been started. The home should be decorated while decisions about any proposed extension work are being contemplated. This will benefit service users and staff, and improve the overall appearance of the home. A statement is held on individual files where equipment or facilities are not provided in service users bedrooms, e.g. locked cupboards. Similarly, for safety purposes the doors to the home are kept locked. Both circumstances have been fully risk assessed. The premises are clean and tidy. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. Communal bathrooms have paper towels and liquid soap available. All cleaning materials are stored in locked cupboards in the laundry room. Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 19 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, 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Suitable staffing levels are being maintained and staff receive relevant training to help them meet service users’ needs. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and good quality care. The home’s recruitment policy and practices make sure that suitable staff are employed and that all necessary checks are made to ensure the safety of all service users. EVIDENCE: The assistant manager said that staffing levels are being maintained although there were staff on sick leave at the time of the inspection, including the registered manager. The staff rota was inspected and shows that sufficient staff are available for each shift. Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 20 The assistant manager said that the change over to Dimensions (the new provider) has been relatively smooth, and that the service users and staff team have coped with this very well. Staff training records at the home demonstrates that planning for future training courses has begun. Staff will complete the mandatory health & safety training such as fire safety, first aid, food hygiene, moving and handling, and infection control. Other training courses include communication, safe handling of medicines, abuse, working with people we support and managing challenging behaviour. Specialist training such as autism and epilepsy is arranged as required. All newly employed staff will complete the Learning Disability Award Framework Induction (LDAF) Course. The home is working to achieve autism accreditation for the service with the National Autistic Society. This will take three years from the point of registration and will involve very specific work with staff and service users. The home has been accredited in the past and is working towards achieving this recognition again. The assistant manager confirmed that all prospective staff complete an appropriate application form and that suitable references are obtained including one from their most recent employer. An enhanced CRB/POVA (police) check is undertaken before their appointment is confirmed. All staff are required to work a probationary period at the home. Foxwood DS0000066844.V320337.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, 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well managed with an open and positive approach. Dimensions monitor the home in various ways to ensure that the service continues to develop as service users want and that the home remains a safe place to live and work in. EVIDENCE: The registered manager, Lesley Goodwin has managed the home for many years. Lesley was on sick leave, and Belinda, the assistant manager was responsible for the home at the time of the inspection visit. Belinda is a qualified nurse (RMNH) and has completed training courses relevant to the service provided. Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 22 The registered manager has undertaken a range of relevant training courses that includes Our Approach (including quality outcomes), Our Purpose (including listening and enabling), Equality and Diversity, and Fire Training for Managers course. In respect of management support from the provider, Dimensions has Training and Human Resource Officers who are available to advise and support the home. Service manager meetings are held monthly. The provider’s monthly visits are one of the ways that Dimensions monitors the service and how the home is being run. These visits include interviews with staff and service users and also include an audit of relevant aspects of the service, including records, environment, complaints received, finance and safety. Any actions that may be needed to address shortfalls are specified. The resulting reports are also part of the home’s quality assurance and monitoring system and are intended to form an annual development plan for the service. This report will include service users, stakeholders and interested parties views on the service provision. The management of Foxwood is currently extended to include managing a nearby sister home, to cover for maternity leave. At the time of the inspection visit Foxwood was without a functioning computer and relying on the sister home to access emails, for printing information and travelling to Dimensions in Worcester for photocopying. This raises concerns for the standard of service at Foxwood, particularly in areas of administration and the reviews of systems and procedures. It is evident that focused time is needed at Foxwood to complete this work. Additional resources should be made available to the home to support the manager and the management of Foxwood. Records show that monthly checks of the fire safety system & equipment, water temperature & storage, fridge, freezers and electrical appliances are completed. Staff are undertaking all mandatory health & safety training topics. Generic risk assessments are in place. Fire drills are being completed. The assistant manager was advised that all persons present during fire drills should be recorded to ensure that everyone receives the required training. The homes fire risk assessment must be updated, as the current risk assessment is dated 2002. Foxwood DS0000066844.V320337.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 2 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 YA1 Regulation 6 (a) Requirement The registered manager must provide an up to date Service Users Guide for each service user. The registered manager shall keep the service user’s plan under review and up to date. The registered manager in consultation with the local fire authority must take adequate precautions against the risk of fire. This means fire risk assessments must be kept up to date. Timescale for action 31/01/07 2. 3. YA6 YA42 2 (a) 17 (3a) 23 (4a) 31/03/07 31/01/07 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 YA1 YA19 Good Practice Recommendations Administrative support should be provided for the home so that essential information such as the Service User Guide and service user care plans are updated. The registered manager should make sure that information regarding the health and welfare of service users is clearly DS0000066844.V320337.R01.S.doc Version 5.2 Page 25 Foxwood 3. 4. YA19 YA42 recorded. The frequency of weight checks should be specified to ensure regularity and consistency of recording. All persons present during a fire drill should be recorded to make sure everyone receives the required training. Foxwood DS0000066844.V320337.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Foxwood DS0000066844.V320337.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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