Inspection on 05/07/05 for Weatherdale Unit

This inspection was carried out on 5th July 2005.

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 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

Weatherdale Unit 12/07/07

Weatherdale Unit 16/06/06

Weatherdale Unit 09/12/05

Weatherdale Unit 20/10/04

Weatherdale Unit 07/04/04

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

CARE HOMES FOR OLDER PEOPLE Weatherdale Unit 31 Weather Oak Harborne Birmingham B17 9DD Lead Inspector Ann Farrell Announced 5 July 2005 th 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 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. Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Weatherdale Unitl Address 31 Weather Oak, Harborne, Birmingham B17 9DD Telephone number Fax number Email 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 427 1607 0121 678 3745 Birmingham City Council Ann Marie Westwood Care Home 10 Category(ies) of Dementia - Over 65 (10) registration, with number of places Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The unit is registered to accommodate 10 adults over 65 who are in need of care for reasons of dementia and associated challenging behaviours. 2 .Registration category will be 10 DE(E) 3. That minimum staffing levels for the residential unit are maintained at 2 care plus a senior member of staff throughout the waking day of 14.5 hours 4. Additionally to the above minimum staffing levels, there must be 1 waking night care a senior on waking or sleeping-in duty for respite care users 5. Levels of staffing must be increased appropriately to reflect the numbers of day care service users 6. Care/shift manager hours and ancillary staff should be provided in addition to care staff. Date of last inspection 20th October 2004 Brief Description of the Service: Weatherdale is a ten bedded respite and day care unit that is situated within a purpose built, local authority residential home. Weatherdale is staffed and managed separately from the rest of the home and is registered with the Commission. It is funded and run jointly the Health Service and Social Services and is designed to offer a variety of support services for carers/relatives looking after older people who have dementia and associated challenging behaviours. Support can be in the form of day care, overnight stays, weekend breaks or short stays. Weatherdale is located in a quiet, residential cul-de-sac off a main road in Harborne. The unit is within easy reach of public transport routes as well as all local facilities including shops, churches, library and swimming baths. It is a single storey unit with its own entrance with a coded lock. The unit comprises of lounge/dining area with a small kitchenette, quiet lounge, office space, laundry, fully equipped bathroom, two toilets and 10 single bedrooms. Lawns surround the building and there is a small, secure paved area with seating and flowerpots that residents have access to. There is limited parking to the front of the building. At the time of the inspection there were no minimum standards available for day care therefore only the residential provision was inspected. Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted on an announced basis on 5th July 2005 over one day commencing at 8.15 am. This was the first statutory inspection for 2005/2006. The manager and the deputy manager were present for the duration of the inspection. During the inspection process the inspector toured the home, sampled residents files and other documentation. The managers, two members of staff and one resident were spoken to. A number of the residents were unable to communicate verbally with the inspector. The inspector received sixteen written comment cards from relatives and health professionals with their comments about the service. The feedback was overwhelmingly positive. Many were highly appreciative of the quality of the service and it was stated that staff were professional, helpful and very caring. What the service does well: Weatherdale provides a unique service for residents who suffer with dementia with challenging behaviour, which is in high demand. This provides support to carers enabling the resident to remain in their own homes. They provide flexible packages of care, which are person centred and may be accessed in times of crisis. The home hold regular monthly meetings with carers to provide support and any information they require. In addition, carers telephone the unit for advice and staff were noted to be mindful of their needs and the support they required. There is a relaxed, homely atmosphere and there are good relationships with the local G.P. service and hospital. The home also holds monthly reviews of resident with the community health team and there are informal reviews with carers. There is a good standard of training including both mandatory training and specialised training in respect of the resident group and over 50 of care staff have completed NVQ level 2. The written feedback from relatives was overwhelmingly positive indicating that they were very satisfied with the standard of care and one stated “ the staff are extremely helpful and very caring towards my husband and myself.” Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 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. Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 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 standard(s) 3,4,5,6 The home has good procedures for the admission of residents to the home and written information is available enabling them to make an informed choice. EVIDENCE: The home provides care to residents with dementia on a respite basis, overnight or day care in order to provide support to relatives or carers. Referrals to Weatherdale are usually taken from health or social care professionals. Following a referral a senior member of staff would undertake an assessment of the prospective resident to determine the needs of the resident and the carer. The assessment could be undertaken in the residents own home or on the unit and include risk assessments such as manual handling and tissue viability. Some had a nutritional assessment. Following an assessment the home writes to carers offering them an appropriate package following consultation with them. On inspection of the assessments they appeared satisfactory. There are adaptations to the physical environment to assist those with mobility difficulties. The unit is able to meet a variety of needs. The practices observed throughout the inspection evidenced that staff were able to meet individual needs of residents e.g. staff were available to provide support with personal care, there was an appropriate range of activities for residents and interactions between staff and residents were good. Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 9 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 standard(s) 7,8,9,10 The home has appropriate arrangements for the management of health care and medication. Care planning has been developed to provide staff with the information required to ensure residents needs are met. EVIDENCE: Since the time of the last inspection the home has undertaken a review of the care plans. On inspection of a small sample it was found that the home had recently drawn up core care plans for residents and they had been evaluated once. When this was discussed with the managers they stated that they plan to evaluate the core care plans over the next three to six months, depending on how often the resident visits the home. Following this they will draw up person centred plans for each individual. In addition to the core care plans they did have a record of activities of daily living and an outline of how each area was being met. The home recorded the food and activities undertaken by residents and a daily entry was made by a carer. There was also an additional information sheet and the managers wrote in a separate book about residents each day. The system of daily recording was rather disjointed and difficult to follow. It was discussed with the managers and they were asked to review the system to enable easy retrieval of information in a logical format that is compliant with data protection. Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 10 The home liaises with the local G.P. practice when required and a doctor would visit where required, but due to the short periods of time spent on the unit this is not a usual practice. The manager stated that if the resident receives support from other health professionals such as district nurses they would continue to visit when the resident is in Weatherdale. In addition, monthly reviews are held with the Community Mental Health Team, where individual residents are discussed. The home receives medication into the home when residents enter and the home verifies details with the residents G.P. Since the last inspection the home has set up an auditing system recording all medication entering and leaving the home. Medication is stored appropriately and on inspection was found to be of a good standard. In some cases there is a need for the home to dispose of medication and a record was commenced on the day of inspection. It was noted that staff respected resident’s privacy and treated them with dignity. There was good interaction between staff and residents, staff were aware of residents needs and had meals with them. All rooms are single and doors have locks with keys available for residents if required. There is also a small quite lounge if residents wish to meet anyone in private. Where medical attention is required it would be given in residents own room. The design of the toilets does not afford full privacy for residents, as they are not fully portioned from floor to ceiling. Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 11 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 standard(s) 12,13,14,15 The management of mealtimes is good and a choice of nutritious food is available for residents. There is a good range of varied activities throughout the day. EVIDENCE: Weatherdale has a pleasant relaxed and friendly atmosphere with staff smiling and greeting people as they arrive. During the day of inspection there was a range of organised activities including a quiz, bingo, watching a video plus the occupational therapist visited and provided hand massage to some residents. There was also television, the radio one resident was knitting and others were chatting with staff. Residents are able to get up /go to bed and wander around as they wish. Visitors are able to visit at all reasonable times and can meet residents in private. The home conducts a carers meeting every month where there is discussion about any areas they wish. The home has also arranged visits from outside professionals to give talks on various topics at the meetings e.g. benefits, dietician, emergency services etc. Written feedback from carers confirmed these meetings occurred regularly. The home receives the main meals from the residential home. There is a fourweek rotating menu with a choice of meals and special diets are catered for where required. On the day of inspection residents were offered a choice, staff sat and ate with residents providing assistance as required. The meal was relaxed and unhurried. Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 12 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 standard(s) 16,18 Residents and relatives were happy and had no complaints. They felt confident that any concerns would be addressed. Residents are protected from abuse by the homes procedures. EVIDENCE: At the time of inspection records indicated that the home had received two complaints. There were only records relating to one complaint available in the home. The manager stated that the complaints procedure was being updated. Written feedback from carers indicated that were completely satisfied with the standard of care given and their perception of staff was such that is they ever felt a need to complain there would be no difficulties. The home has a copy of the local guidance for vulnerable adult procedures and on discussion with staff they were aware of the action to take in the event of an allegation of abuse. Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 13 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 standard(s) 19,20,21,23,24,25,26 There is a relaxed and friendly environment, which is generally well maintained. Some further decoration is required to enhance the appearance of the home. EVIDENCE: Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 14 The building is a ten bedded unit, which is attached to a large residential unit. The home was clean and warm, but there was noted to be a slight odour on early in the morning. There is parking in the main home and a small garden area for residents with potted plants and seating for when the weather permits. There is one combined lounge dining room and a small quite room, which were pleasantly decorated. Some of the furnishings in the lounge were damaged, but replacements had been ordered. There are ten single bedrooms with wash hand basin, call bells and locks to doors. All rooms are adequately furnished and the home has ordered some new commodes, which were noted to be in need of replacement. In addition, some of the bedrooms inspected required re-decoration. There is one large assisted bathroom, which is equipped with a parker bath. Residents would benefit from an additional bathroom with a shower facility to provide a choice. However, the inspector is aware that due to the size and layout of the unit this would be difficult to accommodate. There are two toilets with hand grab rails, but they are not portioned from floor to ceiling. If the maximum number of residents (12) were on the unit this number of toilets could prove inadequate and it is recommended that consideration be given to the addition of an extra toilet. The inspector is aware of the difficulty of accommodating this. Rooms are individually and naturally ventilated and windows are provided with restrainers. All areas are centrally heated, but controls to the radiators cannot be accessed by residents to adjust the heating in individual rooms. Hot water outlets have thermostatic valves fitted to control the temperature of hot water to reduce risks from scalding. There is a separate laundry, which is adequately equipped. A separate room is used for the storage of cleaning materials and at the time of inspection it was noted that the key was left in the lock. The home has a small kitchen and the doors to kitchen units had been replaced, but some of the carcasses and worktop were damaged and will need replacement. Also the ventilation requires attention and it is need of redecoration. On inspection it was noted that some bottles of sauces had been opened and not dated. The home was clean, but some of the carpets may needs replacing due to the slight odour noted. This area will need to be reviewed and appropriate action taken. Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 Staff morale was good, they were enthusiastic and there was noted to be good relationships between staff and residents. Staff training is undertaken and satisfactory staffing levels are maintained during the day. However, review of night staffing levels needs to be undertaken. EVIDENCE: Staff in the home are made up of staff from the Primary Care Trust and Social Care and Health. The staffing levels are being maintained to at least two care staff and a senior member of care staff during the day plus the manager. Overnight there is one or two care staff on duty according to the number of residents who are on the unit. The inspector was concerned that there is only one member of staff on duty overnight when it caters specifically for residents who suffer with dementia and have challenging behaviour. At the last inspection it was identified that the manager and deputy were trying to increase levels to two night care staff. This area will need to be reviewed and a report forwarded to the Commission indicating action to be taken. The unit also has clerical support and the maintenance operative for the residential home carries out everyday maintenance. The home does not have an allocated domestic assistant and this area will need to be addressed by senior managers. The home has an ongoing training programme and currently over 50 of care staff have completed NVQ level 2 and some staff are undertaking NVQ level 3. In addition, the home has student nurses allocated to the unit and on discussion with one she stated staff were friendly, the manager was supportive and keen to teach. Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 16 Although the inspector is aware that both Social Care and Health and Primary Care Trust have rigorous selection and recruitment procedures it was not possible to check these had been applied as the majority of records were held centrally. As at previous inspections both departments will need to ensure the inspectors have access to these records. Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,35,36,38 The manager, who is supported by the senior team, provides good leadership. The home is managed in the interests of the residents and their carers. Their health, safety and welfare is protected. EVIDENCE: The manager is a registered nurse with several years experience and has been in post for a short period. She is supported by the deputy manager who has been working on the unit for a number of years. The manager informed the inspector that she would not be remaining on the unit permanently. The senior managers of the unit must notify the CSCI of their intention in relation to proposing a manager for registration. All residents/day care clients are only on the unit for short periods and the home does not hold any monies/valuables on their behalf. There is a safe facility available if required. The manager stated that regular staff meetings and supervision occurred with staff and this was confirmed on discussion with staff. They stated they Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 18 enjoyed working on the unit and found the managers very good. They felt staff got on well and if there were any problems they were always addressed effectively. Health and safety appeared to be well managed and the inspector was informed that that the Primary Care Trust undertake a health and safety audit every six months. They had evidence of servicing of portable electrical appliances, handling equipment, fire extinguishers. There was no evidence of servicing of the call bell system, although there were regular in house checks. During the inspection it was noted that flammable items were stored under the stairs. These should be removed due to fire regulations. In addition, the entrance door has a keypad lock, which is not linked into the fire alarm system. Records in relation to other servicing is held by the main home and will be checked when an inspection is undertaken. The manger informed the inspector that training had been undertaken in respect of areas such as fire, basic food hygiene, moving and handling etc. In addition, training had commenced for aggression de-escalation techniques and safe handling. However, records of staff training were not available on the unit at the time of inspection. The records of all staff training should be available on the unit for inspection. Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 2 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 2 x 3 2 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 2 3 x x 3 3 x 2 Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 20 no Are there any outstanding requirements from the last inspection? 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 2 Regulation 5(1)(b) Requirement All residnets should be provided with a statement of terms and conditions at the point of admission to the unit. This area was not assessed and is carried forward from 30/12/03. The registered person must undertke a review of the daily recording processes for residents and implement systems that are easy to follow, enable retrival of information that meets data protection guidlines . The registered person must ensure that details of all compliants to the home are available for insepction. They should indicate compliant, investigation, findings, outcome and resolution. The registered person must ensrue the kitchen is redecoarted and damaged unit repaced. Timesclae of 1/7/04 not met The registered person must ensure there is adequate ventilation in the kitchen. Timesclae of 1/2/05 not met. The registered person must ensure all sauce bottles are Timescale for action 30/9/05 2. 7 17(1)(a) 30/8/05 3. 16 22 30/7/05 4. 19 23(2)(b) (d) 30/10/05 5. 19 23(5) 30/8/05 6. 19 16(2)(j) 30/7/05 Page 21 Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 dated when opened. 7. 24 23(2)(d) The registered person must audit all bedrooms and draw up a plan of re-decoration. Forward the plan to the Commission Timesclae of 5/3/04 not met. The registered person must undertake a review of carpets and draw up a plan of repalcement where required. Forward plan to the Commission. The registered person must ensure toilets are partioned from floor to ceiling. Timesclae of 30/1/04 not met. The registered person must ensure heating controls are accessible to residents. Timscale of 30/4/04 not met. The registered person must ensure the cupboard containing cleaning materials is kept locked when not in use. The registered person must undertake a review of night staffing levels and forward a copy of the report to the Commission. There should be a dedicated member of domestic staff for the unit. The manager must ensure that all records as required in schedule 2 of the Care Homes Regulations are available on the unit for inspection. Timescale of 30/12/03 not met. All care staff must receive induction and foundation training to the specifications detailed by TOPSS. This are was not insepcted and has been carried forward from 1/1/05. The senior managers responsible for the unit must submit to the CSCI their proposals to register a manager. Timescale of 5/2/04 30/8/05 8. 24 16(2)(k) 30/8/05 9. 21 12(4)(a) 30/12/05 10. 25 23(2)(p) 30/12/05 11. 26 13(4) 7/7/05 12. 27 18(1) 30/8/05 13. 29 19(1) Sch 2 30/9/05 14. 30 18(1)(a) 30/12/05 15. 31 8(1)(a) 30/9/05 Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 22 not met. 16. 38 23(2) The registrered person must ensure there is evidence on site that the emergency call system has been serviced at least annually. Timesclae of 1/12/04 not met. The registered person must ensure there is evidence on site to indicate the training that staff have undertaken. The registered person must ensure: Flamable items are removed from under the stairs. The key pad on the entrance door is linked into the fire alarm system 30/8/05 17. 38 18(1) 30/8/05 18. 38 23(4) 30/8/05 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. 3. Refer to Standard 21 21 37 Good Practice Recommendations It is recommended that to offer further choice a shower room be installed on the unit. To enhance the facilities for service users it is recommended that an additional toilet be installed. It is strongly recommended that both departments address the duplication of paper work carried out by staff. Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Birmingham & Solihull Local 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 Weatherdale Unit E54 S35597 Weatherdale V228426 050705 AI Stage 4.doc Version 1.30 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!