Inspection on 27/02/06 for Ruby Rhydderch

This inspection was carried out on 27th February 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 but made no statutory requirements on the home.

Other inspections for this house

Ruby Rhydderch 14/01/08

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

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Ruby Rhydderch 2 Ipstone Avenue Stechford Birmingham B33 9DZ Lead Inspector Ann Farrell Unannounced Inspection 27th February 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 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.V285327.R01.S.doc Version 5.1 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.V285327.R01.S.doc Version 5.1 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 usually exceeding six weeks. 10th August 2005 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, each having a lounge and kitchen. All accommodation is provided in single rooms that are equipped with wash hand basin and call bell. In addition, there are a number of communal sitting areas around the home, where residents may sit and smoke if they wish. There is a day centre attached to the home, which is managed and run as a separate entity. Off road parking for two cars is available to the front of the home with further parking to the side of the building. The home has a passenger lift and is accessible to wheelchair users throughout. There are pleasant enclosed gardens to the rear that are also accessible to all residents. The main kitchen is situated on the ground floor with a light, pleasant dining room adjacent where main meals are served. In addition, there is a further small dining room on the first floor. Bathing facilities are situated on each corridor with a choice of shower or bath. The home is situated close to local amenities such as shops, off licence and is well serviced by public transport. Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted on 27th February 2006 commencing at 8.30am. This is the second statutory inspection for the year 2005-2006 and it is recommended that this report be read in conjunction with the previous report. On of the assistant managers was present for the duration of the inspection and feedback was given to two of the assistant managers, who have been responsible for the home over the past ten months as the manager has been on sick leave. During the inspection process the inspector sampled resident’s files by case tracking, which is a process to follow the care provided from the time of the residents admission to the home. In addition, a tour of the home and other documentation in respect of the management was inspected. The assistant managers, four members of staff and approximately five residents were spoken to. There is a stable staff group and residents gave positive feedback. What the service does well: What has improved since the last inspection? The assistant manager stated they were in the process of liaising with the G.P. regarding health checks for residents with chronic diseases. Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 6 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. Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 The assessment process needs to be reviewed and fully completed to ensure that all resident’s needs are identified at the time of admission to the home. Staff training is required to ensure they have the appropriate skills and knowledge to meet resident’s needs who suffer with dementia and challenging behaviour. EVIDENCE: The majority of residents admitted to the home require permanent care, but there are also facilities to provide respite care for a small number of residents. The staff liaise with social workers who provide written assessments or care plans for residents who wish to enter the home. They also invite prospective residents to the home enabling them to view the facilities, meet staff and other residents and partake in a meal. At this stage the staff are able to undertake an initial assessment to determine if they are able to meet residents needs. On inspection of records it was found that they had not been fully completed for some residents who had moved into the home. Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 9 Staff care for some residents who suffer with dementia/confusion and staff require training in this area, which has been highlighted at previous inspections. At the time of inspection it noted that one resident who required considerable assistance and had received a new bed, which he had purchased himself. The bed was rather large and he required moving with the use of a hoist plus other equipment in his room. The inspector did not feel that the room was suitable due to the limited size and the need for equipment to be used. In addition, records indicated that there were times when he was being moved that he became agitated/aggressive and he had hit out at staff on occasions. On discussion with the assistant managers it was felt that this may be due to pain he was experiencing, despite the fact that his medication had recently been increased. The arrangements for this resident need to be reviewed and it was suggested that a senior member of staff should assist when ever there was a need to attend move this resident until other suitable arrangements can be made. The managers had written reports in respect of the incidents, but the Commission had not been notified. It is a requirement under regulation 37 that the Commission should be notified of such incidents. Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 There are systems in place to meet resident’s health needs, but the lack of comprehensive records and follow up cannot guarantee consistency of care given to residents. Auditing of medication need to be undertaken and action taken to address issues to ensure residents receive the medication prescribed by medical staff. EVIDENCE: Senior staff draw up an Individual Service Statement (ISS) for each resident following admission outlining how the resident’s needs are to be met by staff. On inspection of a small sample it was found that some residents did not have an ISS in place, in some cases the ISS had not been updated and did not consistently reflect the care provided. In another file it stated that a resident was unsteady on their legs, but there was no evidence of a falls risk assessment. Nutritional assessments had not been undertaken and some residents had not been weighed regularly. On discussion with the managers at feedback it was stated that the carers are now recording assessments and drawing up care plans following a directive from senior staff, but it appears that they have not received any training in this area. On discussion it was stated that care staff had not received training in this area. Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 11 It is acknowledged that care staff should be involved in the process of assessment and care planning, as they are involved in the day-to-day care. However, it cannot be expected that they should undertake this role without any training or additional time for the process. The manager will need to review this area and take appropriate action. All residents are registered with a local G.P. practice and staff liaise with health professionals from the multidisciplinary team such as district nurses, social workers and continence adviser. Records indicated there were regular visits from health professionals such as the chiropodist, but it was not always clear that residents had opportunity to see the dentist and optician. At the last inspection it was identified that health checks for residents with chronic diseases such as diabetes and asthma had not consistently taken place. One of the assistant managers stated that they were currently liaising with the G.P.’s surgery about this. Whilst touring the home it was noted that one resident was having some difficulty with eating and drinking. The home had purchased some specialised utensils, but apparently she was reluctant to use them. It was recommended that specialist advice should be sought e.g. from an occupational therapist or similar. Medication is provided in a monitored dosage system and is stored in the medical room. On inspection it was found that a number of audits were not accurate; on some occasions there was no record of the amount of medication entering the home so it could not be confirmed that medication had been administered according to the doctors instructions; codes had been used and not defined; there was no evidence of the date or moth on one record chart; drugs usually stored in the controlled drug cabinet had been stored in the medication trolley; controlled drugs had not been countersigned by two staff upon receipt into the home. The home is using oxygen for one resident and had made a notice advising of this. They will need to obtain a statutory notice and ensure the oxygen cylinder is secured. Residents are consulted about their wishes in respect of holding keys to their bedroom door and all rooms have lockable facilities for the storage of valuables or medication. A public telephone is available in a corridor, but if privacy is required suitable arrangements can be made. During inspection residents were well presented, their privacy was respected and staff treated them with respect. A number of residents stated they were happy living in the home, found the staff very good and helpful. One stated, “They look after me well”. Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 A review of the arrangements for activities and stimulation need to be reviewed following assessments of residents past interests to ensure their social needs are being met. EVIDENCE: Residents are free to come and go as they wish and there are no rigid rules. Visiting is flexible and feedback indicated that relatives can visit at any time and were made welcome. Each of the lounges has a television and there is also a television with video recorder, which is used for film sessions in the main dining room. . There is also a pleasant enclosed garden with seating that can be used when weather permits. On discussion with some residents they stated they were bored at times. The manager had employed a maintenance operative at the time of the last inspection with the intention that he would drive the mini bus and take residents out, but this has not occurred to date. The area of activities and stimulation of residents will need to be reviewed and developed further, based on assessment of their past interests and hobbies. Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 13 There is a separate hairdressing room and the hairdresser visits regularly. The home receives a supply of library books from the mobile library bi-monthly and talking books from the blind institute. Staff also run a trolley shop and funds raised are deposited into the comforts fund, which is used for resident’s social activities. Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: This area was not assessed at this inspection. Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26 The décor and furnishings in the communal areas are good providing residents with pleasant areas to sit. Re-decoration of some bedrooms and some maintenance needs to be addressed to enhance the environment and ensure residents safety. EVIDENCE: Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 16 The building is a purpose built residential home, which was cleaned to a good standard and odour free. There is a very pleasant garden and patio area to the rear of the building, where seating is available for use by residents when weather permits. On entering the home there is a pleasant reception area, which is carpeted, but corridors through the remainder of the home are covered with floor tiles and replacement with an alternative would provide a more homely appearance. On touring the home it was noted that some waste bins did not have lids, incontinent pads had been placed in a black bag, bedroom doors were propped open and combustible items were being store under the stairs. Combustible items were removed at the time of inspection. The home is divided into four units and each has a lounge and small kitchen area. The lounges are pleasantly decorated and furnished providing a homely atmosphere. There is one large dining room on the ground floor, which is bright and pleasantly decorated. In addition, a smaller dining room is situated on the first floor. During inspection it was noted that the flooring was lifting to the entrance of the main dining room and first floor toilet plus the carpet in the hairdressing room and room 27 were uneven and pose a hazard to residents. All bedrooms are single and have a wash hand basin and call bell. On inspection of a sample of rooms it was noted that they were pleasantly decorated and had been personalised by residents but required re-decoration. In addition, it was noted that some of the mattresses were dipping in the middle and commodes were damaged. An audit of mattresses and commodes must be undertaken and replacements provided where necessary. A number of bedrooms only have two single electrical sockets, which limits the number of electrical appliances that residents can safely use. At inspection it was noted that one of the covers to the electrical sockets was coming away from the wall and an electrical adaptor was in use. The manager will need to ensure this is addressed and obtain a suitable alternative to the electrical adaptor. Eleven bedrooms have a TV aerial point and three have telephone points. Doors are provided with locks and lockable facilities are available for the storage of valuables or medication. Records indicated that residents are consulted about the door key to the bedrooms. Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 17 There is a range of bathrooms with a bath or shower enabling residents to have a choice of bathing facility. The side of the bath on Windsor unit was damaged and coming away from the bath. There are a number of toilets throughout the home within easy access of dining rooms and lounges. Rooms are individually and naturally ventilated. All areas are centrally heated, but controls cannot be accessed by residents to adjust the heating in their bedrooms. Hot water outlets have thermostatic valves fitted to control the temperature of hot water so reducing the risks from scalding and all of them are now checked on a regular basis. There is a separate laundry, which is adequately equipped and staff undertake the laundering of residents clothing. On inspection, the laundry was not locked when unattended and records from resident’s meetings indicated there were issues in respect the laundry system, but there was no evidence to indicate that they had been followed up. This area will need to be addressed. Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Rotas indicated that staffing levels were not being consistently maintained and this may impact on the care of residents. EVIDENCE: Information from staff rotas indicated that the conditions of registration in respect of staffing levels were not being consistently maintained. If the manager wishes to change the conditions of registration they must formally write to the Commission with their proposal. Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 There is a stable management team with the return of the care manager. The health, safety and welfare of residents needs to be further promoted and protected by ensuring that staff receive updated training and a quality assurance system needs to be implemented. EVIDENCE: The manager is suitably qualified and has been in post for a number of years. She was not available at the time of inspection due to sick leave, but was due to return within a few days. On discussion with staff they stated they were looking forward to her return. Records indicated there had only been one staff meeting since there last inspection and there was no evidence to indicate that issues raised in residents meetings had been addressed. Outstanding maintenance issues were followed up and were found to be satisfactory. Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 20 It was stated the issues in respect of the gas certificate for kitchen equipment will be addressed within the next few weeks as they had been waiting for some parts. Areas in respect of training that need to be addressed include infection control, first aid and basic food hygiene. Currently the home does not have a recognised quality assurance system and this will need to be addressed in order to meet the standards. The quality assurance system should be based on seeking views from various stakeholders and drawing up a development plan indicating outcomes for residents. The home holds monies on behalf of residents and on inspection there appeared to be a robust system with records maintained. Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 21 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 X 2 2 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 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 3 2 X 2 2 2 2 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 2 Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 22 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 OP1 Regulation 4 Requirement The registered person must review and enhance the statement of purpose to provide specific and detailed information as outlined in the guidance given. This area was not assessed and has been carried forward. The registered person must review and update the service user guide to ensure it provides up to date information. This area was not assessed and has been carried forward. The registered person must ensure that each resident receives an up to date copy of the terms and conditions of residency. This area was not assessed and has been carried forward from 30/3/05. The registered person must ensure a comprehensive assessment is undertaken for all residents entering the home. The registered person must DS0000033591.V285327.R01.S.doc Timescale for action 30/06/06 2. OP1 5 30/06/06 3. OP2 5(1)(b) 30/06/06 4 OP3 14 30/04/06 5 OP4 12(1) 30/03/06 Page 23 Ruby Rhydderch Version 5.1 6 OP4 18(1) 7 8 OP4 OP7 37 15 9 OP7 18(1) 10 OP8 13(1) 11 OP8 15 ensure a review is undertaken in respect of the resident identified in the report and appropriate systems put in place to meet his needs. The registered person must ensure all staff undertake training in respect of caring for people with dementia and challenging behaviour commensurate with their position in the home. Timescale of 30/12/05 not met. The registered person must ensure all incidents are reported to the Commission. The registered person must ensure a care plan is drawn up for all residents in the home. It must include all areas of need, outline in detail the action to be taken by staff to meet residents needs, must be reviewed monthly and updated where there are any changes. The registered person reviews the arrangements for drawing up care plans and ensure all staff who compile them receive training. The registered person must ensure: • All residents have opportunity to see a dentist and optician on a regular basis and records are maintained. • Liaise with specialist services such as occupational therapist for advise where required The registered person must ensure; • Nutritional screening is undertaken on admission to the home and is reviewed on a periodic DS0000033591.V285327.R01.S.doc 30/06/06 10/03/06 10/04/06 30/04/06 30/03/06 30/04/06 Ruby Rhydderch Version 5.1 Page 24 12 OP9 13(2) 13 OP12 16(2)(m) (n) 14 OP19 16(2)(j) 15 OP19 13(4) 16 OP19 23(4) basis for all residents in the home. • Residents are weighed on a regular basis. Timescale of 30/10/05 not met The registered person must ensure: • The accurate administration and recording of medication at all times. • Two signatures are obtained for receipt of all controlled medication. • Controlled medication is stored correctly at all times. • All codes are defined. • An accurate record of the amount of medication entering the home is recorded on MAR charts. • All MAR charts clearly indicate the date and month of administration. • Oxygen must be secured at all times and a statutory notice must be obtained to indicate it is in use. The registered person must undertake a review of the arrangements for activities and stimulation taking into consideration resident past interests and hobbies. The registered person must review units in kitchenettes with a view to replacement. Timescale of 30/3/05 not met. The registered person must audit all flooring and and ensure it is safe and does not present a hazard to residents. The registered person must ensure all fire doors are kept closed when not in use. If there is a need to keep them open DS0000033591.V285327.R01.S.doc 10/03/06 30/04/06 30/08/06 10/03/06 06/03/06 Ruby Rhydderch Version 5.1 Page 25 17 OP19 16(2)(c 18 OP24 16(2)(c) 19 OP24 23(2)(d) 20 OP24 16(2)(c) 21 OP25 23(2)(p) 22 OP26 12(1) 23 24 OP26 OP26 13(4) 13(3) they must be linked into the fire alarm system. The registered person must ensure the floor tiles are replaced with an alternative to enhance the homely atmosphere. Timescale of 31/3/04 not met. The registered person must undertake an audit of all mattresses and commodes in bedrooms providing replacements where appropriate. The registered person must undertake an audit of all bedrooms and draw up a plan of redecoration with timescales for implementation. The registered person must ensure there are two double electrical sockets available in all bedrooms. Timescale of 31/3/04 not met. The registered person must ensure the covers to all electrical sockets are well fitting and provide a suitable alternative to the electrical adaptor. The registered person must ensure residents can adjust the radiators in their bedrooms. Timescale of 31/3/04 not met The registered person must follow up issues raised by residents in respect of their laundry. The registered person must ensure the laundry is kept locked when not attended. The registered person must: • Provide lids to waste bins. • Ensure the correct disposal of incontinence pads. • Repair/replace the bath panel on Windsor unit. DS0000033591.V285327.R01.S.doc 30/08/06 30/04/06 30/04/06 30/03/06 30/08/06 30/04/06 06/03/06 10/03/06 Ruby Rhydderch Version 5.1 Page 26 25. OP27 18(1) 26 OP33 24 27. OP38 13(4) 28 OP38 13(3) 29 OP38 16(2)(j) 30 OP38 13(4) The registered person must ensure there are adequate staff on duty at all times and that they meet the conditions of registration. If they wish to change the conditions of registration a proposal should be forwarded to the Commission. Timescale of 30/11/04 not met. The registered person must introduce a quality assurance system and draw up an annual development plan based on feedback from stakeholders. The registered person must ensure the issue identified on the gas safety certificate is addressed. Timescale of 30/10/05 not met. The registered person must ensure all staff undertake training in respect of infection control. The registered person must ensure all staff undertake training in respect of basic food hygiene. The registered person must ensure all staff undertake training in respect of first aid and there is at least one first aider on each shift. 10/03/06 30/08/06 30/03/06 30/05/06 30/06/06 30/05/06 Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 27 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 OP8 OP38 Good Practice Recommendations It is recommended that senior staff follow up health checks for residents with chronic diseases such as diabetes and asthma. It is recommended that the home undertake auditing in respect of accidents. Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ruby Rhydderch DS0000033591.V285327.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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