Inspection on 14/01/08 for Ruby Rhydderch

This inspection was carried out on 14th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ruby Rhydderch 27/02/06

Ruby Rhydderch 10/08/05

Ruby Rhydderch 25/11/04

Ruby Rhydderch 11/08/04

Ruby Rhydderch 24/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Ruby Rhydderch 2 Ipstone Avenue Stechford Birmingham B33 9DZ Lead Inspector Karen Thompson Unannounced Inspection 14th January 2008 08:00 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 Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ruby Rhydderch Address 2 Ipstone Avenue Stechford Birmingham B33 9DZ 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) 0121 784 2195 0121 789 9367 Birmingham City Council (E) Bridged Christina Seelal Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home is registered to accommodate 45 adults over the age of 65 who are in need of care for reasons of old age and may include mild dementia. Registration category will be 45 OP That minimum staffing levels are maintained at 7 care assistants a senior member of staff throughout a 14.5 hour waking day In addition to the above minimum staffing level there are 3 waking night staff a senior awake or on sleeping-in duty Care/shift manager hours and ancillary staff should be provided in addition to care staff Completion of the BTEC Higher Diploma in the Management of Care Services by April 2005 That one service user aged between 50 and 65 can be accommodated in this home to receive interim care for a period not ususally exceeding six weeks. 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Ruby Rhydderch is a purpose built two-storey building that was commissioned in 1974. It is owned and managed by the Local Authority and provides accommodation for forty-five residents for reason of old age for both long term and respite care. The home is divided in to four units, which are individually staffed and have a lounge and kitchen. Meals are served in the main dining room located on the ground floor or the smaller room on the first floor. All accommodation is provided in single rooms that are equipped with a wash hand basin and call bell. No en-suite facilities are provided. In addition, there are a number of communal sitting areas around the home. The floors are accessed by a shaft lift and the home has hoists to assist those who suffer from restricted mobility in completing transfers to respective rooms. Assisted bathing facilities are available in each unit which provide residents with a choice of bath or shower. The corridors are wide and provide good access for wheelchair users. There are pleasant enclosed gardens to the rear that are accessible to all residents. The main kitchen and laundry rooms are situated on the ground floor. There is a day centre attached to the home, which is managed and run as a separate entity and is not inspected by CSCI. Off road parking for two cars is available to the front of the home with further parking to the side of the building. . Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 5 The home is situated close to local amenities such as shops and is well serviced by public transport. The prices for these services vary depending on the level of care required and financial assessment by the Department of Adults and Communities. Fees at the time of inspection ranged from £64.65 to £482.00 per week. Hairdressing, chiropody, dry cleaning, dental care, optician appointment and toiletries are not included in the weekly fees. For up to date fee information the public are advised to contact the home. Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by us is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. This inspection was unannounced and conducted over two days commencing on 14 January 2008. The manager was present for the duration of the inspection. Information was gathered from a number of sources: a questionnaire was completed prior to the inspection by the manager (AQAA) and on the day of the inspection a tour of the building was undertaken, records and documents were examined in relation to the management of the home, conversations took place with managerial and care staff plus visitors and residents. A number of residents were unable to communicate their views verbally to the inspector so direct and indirect observation was used to assist with the inspection process. Three residents who live in the home were ‘case tracked’ which involved establishing the individuals’ experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes of their lives in the home. Tracking people’s care helps us understand the experience of people who use the service. The inspector would like to thank the residents, management and staff for their hospitality throughout this inspection. The quality of this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the service does well: This is a well managed home with a core staff group committed to delivering good care to residents. The home has lots of communal space, which provides residents with a choice of areas they can access for company or quiet. There are good links with an array of multidisciplinary health professionals, which ensure that residents’ health needs are being met. Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 7 Residents’ rooms are individualized with personal possessions so providing a more homely environment. Residents’ clothes were nicely laundered and they looked well presented. Staff interaction with residents was relaxed and friendly ensuring a happy atmosphere within the home. Residents and relatives comments included “staff were kind” and “staff friendly and helpful”. Staff are recruited safely ensuring all required checks such as CRB disclosure are made before appointment; protecting residents when new staff are employed. Visiting was flexible and the staff welcome visitors, so residents are able to maintain contact with friends and family at a time that suits. The staff were able to demonstrate that pre-admission documentation was comprehensive, ensuring that residents are not admitted to the home unless their needs can be met appropriately. Money which is held on behalf of residents by the home, was accounted for and there were good systems in place to ensure residents’ finances were protected. Sixty six percent of staff have the NVQ2 or above qualification in care, which demonstrates a core group of staff have attained a certain level of knowledge and skill to care for residents. What has improved since the last inspection? Carpets have been replaced in a number of areas and refurbishment of kitchenette areas has taken place, so enhancing the environment for residents. The home now has a hardwiring electricity certificate which guarantees that the meets the required standard to ensure the well being of residents and staff. The home has devised a health log , which allows for easy monitoring and retrieval of information about a residents health needs. A staff training matrix has been implemented which give an overview of training needs and allows for quick identification of deficits so that the appropriate action can be taken. Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 8 The pre-admission documentation was found to be comprehensive therefore ensuring no resident moves into the home without staff being fully aware of their needs. 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. Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 9 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 Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. 3. Quality in this outcome area is good. The pre-admission assessment process was consistently comprehensive and therefore residents can be assured their needs will be meet when moving into the home. Contracts are not sufficiently detailed to inform residents of their rights and obligations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents files sampled were found to contain a contract, but the contract did not state which bedroom they would be occupying or individual fees. Fees are calculated on an individual basis by the social work team based on residents’ needs and finances, however the home will still need to state the fee to be charged in the resident’s contract. Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 11 A number of residents’ files were inspected to determine the admission process. The pre-admission assessments information obtained by the home met the standard ensuring staff had sufficient information to meet residents needs when moving into the home. Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10. Quality in this outcome area is adequate There was evidence of good multidisciplinary working taking place on a regular basis. The arrangements for medication administration were variable potentially placing residents at risk. Care planning records do not demonstrate that residents needs are being consistently met and could potentially place residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care records (ISS) of three of the people living at the home were looked at in detail and other records were sampled. Care plans are based on the assessment that is completed before the person moves into the home. Risk assessments for manual handling, skin integrity, challenging behaviour and nutrition were found in the care plans sampled. However finding and Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 13 strategies from these risk assessments were not always being linked into the care planning instructions for staff. For example a nutritional risk assessment had been completed and had identified the need for this particular resident’s food to be presented in a certain way but this was not acknowledged in the care plan. The care plan is a tool, which gives staff instruction on how to care for residents but also is used to monitor how effective this care is. The majority of daily recordings were not always sufficiently detailed that care delivery and the monitoring of needs could be ascertained or demonstrated to have been met. Information from these daily records was not always being linked back into the care planning strategies. There were no protocols in place for diabetes, epilepsy or managing challenging behaviour. Although the home has a policy and procedure for managing challenging behaviour. An individual protocol must be in place for each resident who has been assessed as needing such strategies to promote and protect their welfare. Residents’ files demonstrated that a variety of multi-disciplinary team members were visiting the home and referrals were being made. The home has a health professional log for each resident which means information can easily be retrieved about residents’ health need interventions. Staff were also able to demonstrate a pro-active approach to meeting residents health needs. One relative spoken to during the inspection stated they were always informed of a change in their relative’s condition if and when this occurred. The home accepts residents with dementia. Staff were able to demonstrate that residents needs in relation to cognitive impairment were being meet via a variety of means such as monitoring behaviour and referral to the appropriate professionals where required to ensure needs were met. Some staff have received training in dementia awareness to provide them with the skills to meet residents needs. However only three staff have received training in challenging behaviour. Whilst staff were making the appropriate referrals, records need to demonstrate whether staff can and have identified triggers for such behaviour. Some staff have received training in the Mental Capacity Act and the implications this has in relation to the care they give. Staff spoke positively about the Mental Capacity Act Training and all staff should receive this to ensure they are fully aware of the implications of this Act on their practice and how it promotes and safeguards the rights or residents. The management team stated that all staff who dispense medication have received accredited medication training. The medication trolley is stored in a medication room. Medication trolleys were observed to be clean and organized. The home’s medication system consisted of a blister and box system. Staff photocopy the original prescribing scripts (FP10), which are used to check medication into the home. The majority of sample medication audits were correct however staff are not automatically recording carried-over medication from the previous month which means auditing is not always possible. Also staff are not recording when medication has to be discarded and reissued, again making auditing problematic. Residents are empowered to Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 14 self medicate if they wish. Those residents self-medicating did not always have a risk assessment in place or have regular compliancy checks being carried out by staff at the home to ensure the safety and well being of residents. Medication for residents who were self medicating was not always found to be stored in a lockable facility in residents’ bedrooms. Self medication is to be encouraged for those who wish to do so but staff must ensure basic safety checks are carried out and formally recorded. The medication room was found to be warm and on some occasions recorded to be above 25c. Medication stored at above 25c will be outside the product licence and therefore its stability and effectiveness impair. The home must review systems in the home to reduce the temperature in the medication cooler room or find an alterative storage area. There was good interaction between residents and staff observed. Residents were appropriately dressed for the season. Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12.13.14.15 Quality in this outcome area is good Visitors can visit at times that are suited to them enabling residents to maintain contact with them. Residents are able to exercise choice in their daily lives. Activities are occurring in the home but require further work to ensure they are tailored to residents previous life experiences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Activities were taking place inside and outside the home. The inspector was informed that the home can access a minibus to take residents out at weekends. Residents can also visit the day centre, which is attached to the building if they wish to take part in activities which are occurring there. Staff are recording what activities are taking place for residents in their care plan. Some staff have received training in life book history recording. This formal documentation of residents’ individual life is essential to ensure residents life experiences matches their expectations and preferences of that which is offered by the home. The Care Manager informed the inspector that the home Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 16 was in the process of devising a twelve month activity plan/ programme for residents. Residents confirmed there were no restrictions on their activities and that they could go to bed when they wanted and get up when they liked. Visitors are welcomed to the home and offered drinks with the residents. Residents confirmed that they were able to leave the home and return with no restrictions. Some residents had been away for the Christmas period visiting family and friends. Staff chatted to during the inspection were able to demonstrate an individual approach to residents care. One relative commented that they visited on a regular basis and t6hey “cannot fault the home at all” and they were always made to feel welcome and always offered a cup of tea. Staff were observed to assist residents discreetly and sensitively. The management team assist with serving of breakfasts. This is positive as it ensures that residents have regular contact with the management team and any concerns can be dealt with speedily. This visual presence of the management team reinforces the home’s open door policy. Tables were laid nicely with linen tablecloths and condiments. Menus had been revised since the last inspection and were based on a nutritional advice. Residents’ comments about food were positive. A good stock of fresh, tinned and frozen food was available ensuring residents had a choice available to them. Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16.18 Quality in this outcome area is good Complaints and concerns are dealt with in a sensitive and professional manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a comprehensive complaints procedure and these are available in a number of formats within the home. The home has received two formal complaints since the last inspection. There have been no adult protection referred to Adults and Communities since the previous inspection. The home was able to demonstrate that they had investigated the concerns appropriately, professionally and an action plan was drawn up to ensure that any findings were addressed. Residents and relatives spoken to during the inspection stated that they would go to the management team with concerns and that the management team was approachable. Arrangements for protecting residents within the home were in place. The Care Manager informed the inspector they had a copy of the multi-agency guidance policy and procedure. Approximately 60 of staff have received training in adult protection. Staff interviewed during the fieldwork visit were able to demonstrate a good knowledge in relation to abuse and safeguarding Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 18 procedures. All staff will need to receive this training to ensure no weakness exist in the protection of vulnerable adults. Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19.20.21.22.23.24.25.26 Quality in this outcome area is good Progress has been made in addressing outstanding maintenance issues however further work is required in a number of areas to ensure residents safety and well being. Residents’ private accommodation is suited to their needs and personalised according to their tastes and preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is a two storey building and was found to be clean and odour free on the day of the inspection. Residents have a number of lounges and sitting areas they can access. Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 20 Bedrooms are of single occupancy, are individually and naturally ventilated, and windows are fitted with restrictors to prevent accidents occurring. The rooms of those residents whose care plans were reviewed were visited. The bathing facilities are assisted to ensure residents with mobility restrictions can access them. Residents raised concerns with the inspector as to the bathing facilities in the home. If the bath plug is not in when the toilet is flushed in the bathroom then black liquid reappears up though the bath plug hole. This was discussed with the Care Manager at the time of the inspection and the issue has been looked at but has never been resolved. The home needs to consult with public health and needs to ascertain whether this liquid is hazardous to health and what they can do to reduce this risk. The hot taps was found to be running cold in one of the bathrooms and the inspector was informed that this was due to the boiler needing a new valve. The Commission was not informed of this and maintenance issues need to be resolved swiftly than at present. The laundry and kitchen rooms were visited. They were found to be tidy, well organised and with the appropriate working equipment Aprons and disposable gloves were available to staff to protect residents from the risk of infection. Staff wore white protective aprons for all tasks they carried out to ensure lack of cross infection however it was discussed with the Care Manager (the implementation of blue aprons for staff when serving food). This is a good practice recommendation as it ensures staff remember to change aprons according to the tasks. The home has made progress in a number of areas in addressing outstanding maintenance, redecoration and refurbishment issues. A new carpet has been fitted in the reception area of the home, a new shower area has been installed in the home ensuring each unit has two bathing facilities that residents can access, and a new dining room and kitchenette areas has been created on the top floor of the home. A number of residents bedrooms have been redecorated and furniture replaced. Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27.28.29.30 Quality in this outcome area is adequate Staffing levels are adequate to meet the needs of residents. The recruitment and selection procedures ensure that residents are protected. The home has a committed workforce but training has elapsed in some areas and this needs to be resolved so that residents receive a service from a competent and skilled team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were thirty-three residents living in the home at the time of the inspection. Rotas demonstrated seven to five carers along with senior staff support is available during the day. There are three night staff on duty with a senior member of the team sleeping in the home, but available in case of emergency. Recently recruited staff files were inspected and it was found that a satisfactory recruitment process had been implemented with an application form, health declaration, two references and Criminal Record Bureau Check ensuring residents are protected by the employment of new staff. Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 22 Twenty-one of the thirty one staff have completed NVQ 2 or above bringing the percentage of staff with this qualification to approximately 66 , ensuring that staff have the skills and competences to meet the needs of residents. Staff files were sampled for certificates to demonstrate training had taken place and these were found to be available. The home has a training matrix, which gives an overview of training that has occurred for all staff working at the home. The training matrix identified shortfalls in manual handling, first aid, food hygiene, adult protection and challenging behaviour The inspector was informed that various staff have been nominated recently to attend these courses. The induction programme meets the Skills Council standard and is carried out at the home and also at the providers training venue Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31.33.35.38 Quality in this outcome area is good. This is a well managed home run for the benefit of residents. The health , safety and welfare of residents and staff are generally promoted and protected but further work is required to ensure that this is comprehensive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Care Manager with a wide breadth of experience and knowledge. The Care Manager is assisted by a management team and group of staff that work well together as a team. There was a friendly happy relaxed atmosphere in the home. Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 24 There is a written record of residents’ money with receipts. Money is held individually and securely. The arrangements for the safekeeping and financial transactions of residents’ personal monies are robust, so protecting residents’ finances. The home has various systems in place to monitor quality assurance, which include environmental checks, and audits carried out against CSCI standards, along with resident, staff and quality assurance meetings. The home had conducted resident and staff surveys, which were being analysed. From the information gathered the home should be able to demonstrate that the service is being tailored to meet residents’ aspirations and needs. Health and safety matters on the whole were well managed. A fire risk assessment was in place. Fire drills for staff had occurred two times in the past twelve months. The maintenance operative is carrying out checks in a number of areas, such as, fire equipment, call bells and emergency lighting. There was evidence that hoists were being served and maintained. The home was unable to locate the most recent lift-servicing certificate at the time of the visit. Gas appliances were being serviced and had the appropriate safety certificates. The home had recently had a health and safety inspection carried out and a letter received by the home following this was positive about how staff and management responded to such issues. Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 2 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 3 3 3 3 3 2 2 1 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 3 x 2 Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 12(1) Requirement Timescale for action 30/04/08 2 OP9 13(2) Residents who have conditions or needs such as diabetes, epilepsy or challenging behaviour must have individual protocols drawn up. These protocols will ensure staff have clear instructions on what to do if the resident becomes unwell or demonstrates changes in normal behaviour to maintain the residents safety and well being. Self medication risk assessments 30/04/08 must be carried out along with compliancy checks on a regular basis to ensure the well being of residents. 30/04/08 The home should review the temperature of the medication room and put systems in place to ensure the temperature does not exceed 25c so that the stability of the medication is not compromised. 3 OP9 13(2) 4 OP26 16(2)(j) The home must consult with environmental health about the DS0000033591.V353109.R01.S.doc 30/04/08 Ruby Rhydderch Version 5.2 Page 27 baths discharging a fluid when the toilets are flushed. A risk assessment must take place along with action identified to demonstrate the home has reduced any possible risk to residents. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP2 Good Practice Recommendations All residents must receive an up to date copy of the terms and conditions of residency. This must include details of room to be occupied, fees and services not included. 2 OP7 Assessments of residents needs must be drawn up into a care plan which clearly instructs and guides staff on how to deliver the appropriate care based on residents needs, preferences and choices. These care plans must be reviewed regularly to ensure that the care being given is appropriate and is meeting the residents needs. It is recommended that the home obtain a copy of the Department of Health guidance “Mental Capacity Act “005 residential accommodation” published July 2007 Medication audits are carried out in relation to general medication management and staff practice. If issues are found then the appropriate action must be taken to maintain the well being and safety of residents. Residents individual preferences and choices must be reflected in the activities available within and outside the home. An activities programme must be drawn up to reflect this. Residents who have a number of electrical items in their bedrooms should have a two double electrical sockets fitted. Thus ensuring residents can use and bring in their DS0000033591.V353109.R01.S.doc Version 5.2 Page 28 3 OP30 4 OP9 5 OP12 6 OP24 Ruby Rhydderch 7 8 9 OP25 OP26 OP30 own personal electrical equipment. The boiler valve must be repaired to ensure that residents have hot water available throughout the home. The use of different coloured aprons for staff should be reviewed to distinguish between personal care and serving food. All staff must receive up to date training in fire awareness, food hygiene, challenging behaviour, manual handling, health and safety, Mental Capacity Act, adult protection and first aid. Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Ruby Rhydderch DS0000033591.V353109.R01.S.doc Version 5.2 Page 30 - 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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