Inspection on 01/06/06 for Woodridge Road

This inspection was carried out on 1st June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 37 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodridge Road 09/01/07

Woodridge Road 19/12/05

Woodridge Road 02/08/05

Woodridge Road 07/01/05

Woodridge Road 29/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Woodridge Road 6a Woodridge Road Aston Birmingham West Midlands B6 6LN Lead Inspector Alison Ridge Unannounced Inspection 1st June 2006 09:30 Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodridge Road Address 6a Woodridge Road Aston Birmingham West Midlands B6 6LN 0121 240 4480 F/P 0121 240 4480 maggieoakley@southbirminghampct.nhs.uk 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) Focus Futures Ltd South Birmingham Primary Care Trust Mrs Margaret Judith Oakley Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Residents must be aged under 65 years. A maximum of 4 service users may be accommodated for reasons of learning disability Two named service users over the age of 65 years can be accommodated providing the home can demonstrate it can meet their needs and this is subject to periodic review. 19th December 2005 Date of last inspection Brief Description of the Service: 6A Woodridge is a modern bungalow, situated in a quiet cul-de-sac in Aston. At the time of inspection the residents were all female, two of the service users were over 65. The home is close to main roads that are served by public transport, enabling travel into the city centre, and the One Stop Shopping centre. The home is purpose built. There are four single bedrooms, a communal assisted bathroom, shower room, laundry, kitchen, dining room and lounge. There is off road parking for approximately three cars. The home has a tidy garden at the rear, which has facilities for service users to sit out, and undertake gardening. The home has a very stable staff team, with few vacancies. The home has a registered manager. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced, and took place over one whole day. During the visit the inspector was pleased to meet all four of the women who live at Woodridge Road, staff on both the early and late shift and the manager. Information used in this report was collected by spending time with the women and observing the care and support they received. Records about care, staffing and health and safety were all assessed. The inspector extends her thanks to all four of the women, who kindly agreed to show her their bedrooms. Three staff were interviewed. The manager returned a CSCI pre-inspection questionnaire. No comment cards were received from relatives, professionals, or the people living at Woodridge Road. This is a home that CSCI is concerned about. The needs of the women living at the home are not well planned for or monitored. Observations and records showed that the women continue to be at risk from each other, and that they are subject to verbal and sometimes physical harm. This home will receive additional visits to ensure the safety and welfare of the women. What the service does well: What has improved since the last inspection? Generally the number of staff on duty has increased. It appeared that the morale and motivation within the staff team had increased, and this in turn was leading to a greater number of opportunities for the women. The staff team now includes two seniors as well as the manager, which should enable more development work to be done. This in turn should improve the outcomes Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 6 for the women living at Woodridge, as they will have their needs better planned for and met, and an increased number of opportunities to undertake interesting activities. Medication management had improved although this still wasn’t great. Staff are now checking and recording medication as it comes into the home, is given, and when it is disposed of. This means that mainly the women are getting the right medication at the right time. The manager arranged for some of the women to see a Speech and Language therapist, to establish if they have any special needs regards eating and drinking. This is good, as one person has been referred for more tests, and the other person has no special needs in this area, which means they can eat a wider range of foods. The smell in the home had got better in the shower room, as the fan was working. A new carpet had been ordered for the lounge, which the manager thinks, will help the bad smell in this area of the home. Staff had got better at undertaking and recording health and safety tests. The fire alarm, emergency lighting, fridge/freezer temperatures and hot water delivery temperatures were all being well managed. What they could do better: The manager must ensure that each of the women has a plan of care. These must inform staff of the persons needs, how they are to be met, and any preferences or wishes of the person regards these needs. This work has been outstanding for a long time, and is urgently required. The record of food that people eats needs to improve to show that a balanced diet is being offered, and at least five portions of fruit and vegetables are made available each day. The women must all have plans of care to inform staff of their health care needs and how these are to be met. The manager must ensure health needs are monitored, and that the action required by health professionals undertaken. The medication management needs to further improve to ensure that all required medication is available, and that the medicine records accurately show the medication prescribed. The home needs to get better at planning for and meeting needs that can place other people living or working in the home at risk of harm. Staff need to check the money of the women to ensure they are getting the right benefits. Staff need to show how they decide to spend large amounts of a Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 7 persons money-especially where the person finds it difficult to understand or agree to this. The home needs to be improved by the fitting of a new kitchen, by the redecoration of two bedrooms, and by the replacement of some furniture. The owner of the home needs to provide a place where conversations and meetings can be undertaken in private. It is not acceptable that staff use peoples bedrooms to undertake supervisions or meetings. The manager needs to ensure all staff working at the home have the right qualifications, and that before they start work in the home, that all the right checks are made. Checks need to be updated when they run out. Food Hygiene practice needs to get better to ensure that dry food goods are stored air-tightly, and that chilled products are used before they go out of date. Staff need to get better at checking this, to ensure they food people eat is good quality. The management of the home needs to improve to ensure that the needs of the women are well planned for and met, that requirements are met, and that the home operates safely and efficiently. 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. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): X Not assessed at this inspection. EVIDENCE: There have been no new admissions, and there are no service users vacancies. These standards were not assessed. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users plans do not contain detailed, personalised information about the persons care needs, and how they are to be met. Risks posed by, and which service users are exposed to were not well assessed or controlled. Staff store information securely, but do not have a private area in which to discuss needs, which can result in confidentiality being broken. EVIDENCE: The plans of two service users were assessed. The care documents in one of the files remained unchanged. In the second early work to develop the content of the file was evident. In one file a set of goals were available, which included increasing mobility, loosing weight, going on holiday, and increasing contact with the persons family. No context in which these goals had been identified or set was available. It was not possible to establish who had set them, who was supporting the service user to achieve them, how they were being worked towards, a target or review date. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 11 The inspector was seriously concerned that known needs including night care, manual handling, personal care, continence, epilepsy and pressure care was unplanned for. The plans did not show any consultation or involvement with the service users. The manager showed records of two pieces of consultation that had been undertaken regards household matters. This was considered very positive. It was of concern that for both service users tracked large amounts of personal money had been spent. Evidence of how this had been explored, and decided upon, or that it was in the service users best interest was not available. Risk assessments were available, and each had a sheet attached indicating they had been reviewed. The inspector continues to recommend the care plans and risk assessments be linked or that signposts which direct the reader to supporting documents be introduced. There were key risks noted during the inspection that were not risk assessed. The assessment for one service user regards community access stated a two to one staff ratio was required. During the visit the service user went out twice on a one to one, indicating either practice or the assessment needs to be reviewed. One risk assessment for stairs was assessed. The assessment stated there were no stairs in the home, yet it was reported the location the service user was visiting had numerous stairs, thus this assessment failed to assess this risk. All information regards service users was securely stored. It is of concern that no private space to undertake meetings, reviews, or make referrals for service users is available, which results in staff having to use service users bedrooms, or undertake these activities in communal areas. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users do have opportunity to undertake activities in the home, and the community. Opportunities for personal development were poor. Service users are supported to stay in touch with their family, and people important to them. A range of food is provided, staff need to accurately record what is offered and eaten to ascertain service users are receiving a varied and nutritious diet. EVIDENCE: Opportunities for personal development were found to be limited. The service users don’t undertake any formal learning or development activities. Personal development in areas such as household tasks and personal care had not been planned for. The number of opportunities to undertake leisure activities had increased since the last inspection. It was positive to see in daily records that opportunities to access the community had increased. During the morning of inspection one service user went out, and three service users appeared to really enjoy an in house Karaoke-sing along. In the afternoon a further two service users Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 13 accessed the community, while the remaining two service users interacted with staff. Daily records showed other opportunities provided had included shopping, a disco, hair and beauty and eating out. The daily records showed that service users are supported to stay in touch with their family and people important to them. It was pleasing to see the positive reaction from two of the service users when staff talked about their family. It was positive to see family had been invited to celebrate service users birthdays, and special occasions at the home. The menu, and food available in the home indicated that an interesting and varied diet was being offered. The daily records did not evidence that the amount of fresh fruit and vegetables being offered was adequate. Staff the inspector spoke with considered this to be recording error. One staff interviewed commented that the food provided was one of the homes strengths, and that most meals were cooked from scratch, with little processed or convenience foods being provided. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users had been supported to undertake personal care to a good standard; this area of care was not well planned for. Service users healthcare needs and health monitoring was not robust, and could result in service users becoming ill. Medication management had improved, although some shortfalls were noted which must be addressed to ensure service users get the right medication at the right time. EVIDENCE: The service users were all dressed in a style very individual to themselves. Where this was the choice of the individual they had been supported to wear make-up, jewellery, and attend to their hair and nails. One service user the inspector spoke with was very pleased with the opportunities provided to her regards this area of care. The plans of care did not inform staff of the service users specific personal care needs, or how to meet these. Service users had been supported to attend routine health screening with the dentist, optician, chiropodist and doctor. The records regards this were much Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 15 clearer. It was disappointing to find that the recommendations from a visit to the dentist in April 2006 had not been implemented for one of the service users tracked. Service users have known health needs, and have specific health risks, which were not all well planned for. One file identified a service user to be at risk of constipation. No bowel movement had been reported between May 14 and 27th. No staff had monitored this, and it was apparent this area of need is not being well managed. One service user tracked was recorded to be overweight. No plan to support her towards a healthy weight was in place, and records of weight monitoring recorded she was last weighed in May 2005. The inspector raised concern about the accuracy of weight records as the person was recorded to have weighed 10 stone 11 pounds in January 2005, 12 stone 1 pound in April 2005, and 11 stone 1 pound in May 2005. The manager believes she was weighed in May 2006, but that records of this were not completed. No action taken was taken at the time to validate the records or ensure the persons well being. Service users have some difficult to manage behaviours, which include shouting out, being verbally abusive, stripping off clothes, and soiling. Neither reactive nor proactive strategies were available to underpin these needs. Some monitoring of the behaviours had been undertaken, but it was not evident how this information was being used to inform or direct practice. The day-to-day medication management had improved, and it was positive that records of receipt, administration and disposal were now being completed. A serious medication error had occurred since the last inspection, and it was evident this had been addressed with the staff team, and people involved. Not all staff had received accredited medication training, and this remains an outstanding requirement from the previous inspection. One product was available on the MAR chart that had been discontinued, two prescribed products were not available, and the inspector found one cream in a service users room, which was not listed on the MAR. These shortfalls need to be addressed. It is recommended that PRN pain relief be explored and obtained for all service users, in the event of them having a minor illness. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Risks service users pose to each other continue to be poorly assessed and managed, which could, and has led to service users being physically or emotionally harmed. EVIDENCE: The home has received no complaints. The inspector is aware the provider has a robust complaints procedure, which would ensure concerns raised are dealt with well. This was not viewed at this inspection. The inspector remained concerned for the physical and emotional welfare of the service users, regards risks they pose to each other. It was positive to see that one service users needs in this area had been raised in a multi-disciplinary review. The plan in place regards this remained unchanged, and unsatisfactory. The had this The manager described one service user as “Slap Happy”, and reported she been slapping service users and staff. No plan or monitoring to address was available. inspector remained concerned that this area of need is not well managed. The security of service users possessions while in the home was raised with the manager. It is required that the height of the border fence be reviewed, to ensure service users items are safeguarded when the back door is open. The records of service users personal monies were in good order, and it was evident staff check these at handover. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 17 It was of concern that no clear record of the benefits due to, or received by each service user was being maintained in the home. It is required this be commenced. It was noted that service users personal money had been spent to fund meals and leisure which should form part of the contracted price. It is required this be reviewed and the money reimbursed if required. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The décor and furnishing of the home requires improvement to ensure service users live in a clean, comfortable and well-maintained property that can meet their needs. EVIDENCE: Woodridge Road is a friendly and domestic home. The inspection identified that some areas of the premises now require urgent work to ensure they are safe, hygienic and well presented. The kitchen appears very worn. The surface of the doors, and inside cupboards has started to break down, and can no longer be kept clean to the required standard. It is an outstanding requirement that this be addressed. Two of the four service users bedrooms require attention in the near future. One was outstanding since the last inspection. This room appears very worn, and the papered walls do not allow effective cleaning. The walls in this room had dried faeces, which staff reported could not be removed. This room requires urgent attention. Some pieces of bedroom furniture-such a chests of drawers also appeared heavily worn, and should be scheduled for replacement. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 19 The quality of the lounge furniture was of concern, the suite was heavily worn, smelt offensive, and the fabric was starting to shred. The TV cabinet door was broken. It was positive to hear that the lounge carpet was to be replaced. Service users all have individual bedrooms. The work undertaken to personalise the rooms, and obtain some new luxury cushions and throws was pleasing. It was positive to see the work staff had supported service users with, to put up photos and pictures of their choice. The manager reported that a new piece of equipment had been ordered for one service user, and the physiotherapist delivered a piece of equipment for another person during the inspection. The general standard of cleanliness was acceptable, with the exception of the aforementioned walls, kitchen cupboards and lounge suite. It was of concern that no clear procedures, or infection control training had been provided to staff considering the frequency with which they have to clean up faecal accidents. Food hygiene practice was identified as requiring improvement. Dry goods required sealing, a pack of out of date yogurts were found in the fridge, other chilled food products, which had been dated when opened, had passed the best before date. It was of concern that each day staff had signed to say they had checked the fridge and the best before dates, yet this had clearly not been undertaken. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. It was not possible to establish that the staff provided had been trained in the required areas, or that full checks had been made prior to them starting work in the home. EVIDENCE: The staff on duty at the time of the inspection showed a positive regard for the women they were supporting. A friendly and relaxed atmosphere was maintained in the home throughout the visit. The number of staff provided has increased, and this has had a knock on positive effect on the amount of opportunities and activities provided. Staff reported that The training provided to staff employed, could not be fully established. Some records of training were available on file. These did not evidence that all staff had up to date mandatory training, or that specific training in areas such as ageing, infection control, Epilepsy, Brain injury, continence or confrontation had been provided. It is required that a review of training provided and required be undertaken, and the required training provided to all staff. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 21 It was positive that training to NVQ level 2 had been undertaken by over 50 of the staff team. The recruitment files of five staff were assessed. None of these contained the full compliment of staff records as required. Documents including ID, references, induction, health clearance, and in one case up to date CRB certificate was missing. Staff had received regular and detailed supervisions. These covered personal issues, training and performance. The frequency of these was adequate to meet the bi monthly target. It was of concern that staff are using service users bedrooms to undertake supervisions in the absence of a staff office, or private space. This is clearly unacceptable, and alternative arrangements must be made in the short term, and in the medium term, plans to address this issue must be made. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. It was not evident that EVIDENCE: The home has a registered manager in post, who shows a high level of commitment to the service users and staff team. The progress made towards service improvement and meeting previously made requirements was disappointing, and 21 of the previously made 36 requirements have been carried forward as unmet. The trust undertakes quality audits in the area of nights, care, weekends and lay visits. The records of these were not available in the home, and the manager believes it is in excess of a year that one was last undertaken. The provider and service manager had undertaken regulation 26 visits. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 23 The quality and effectiveness of these was reviewed during the inspection, when it was evident that shortfalls identified had not been picked up in the regulation 26 audits. These must be reviewed and improved. There was a current certificate of insurance and registration on display. The quality of record keeping requires improvement. Many of the files assessed had both current and historic information, which did not enable easy access to the required information. The work undertaken to address this issue in staff files, and to cull service users files was positive. The health and safety of service users, visitors and staff is generally well protected by the regular testing and servicing of appliances. It was not evident that all staff had received the required mandatory training (Or updates), including fire safety, manual handling and food hygiene. There was an up-to date fire risk assessment available in the home. Three of the identified shortfalls had not been signed as met, addressed or further explored. It is required that the manager obtain confirmation that a Legionella test has been undertaken, and that the results of this are satisfactory. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 1 25 2 26 2 27 1 28 1 29 1 30 1 STAFFING Standard No Score 31 X 32 2 33 1 34 1 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 1 2 2 LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 1 2 X 1 2 1 1 X 2 X Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15(1) Requirement Unmet from last two inspections. Service users plans must evidence their aspirations and goals and how these are to be met. Unmet from last two inspections. Service users plans must evidence consultation with the service user or their representative. Goal setting for service users must clearly show: who has set the goals, how they were agreed upon, who is responsible for meeting them, how it will be identified if they are met, when the goal was set, or who the goal is intended for? Unmet from last two inspections. Service users must be offered opportunity to decision make regarding their care and lifestyle. Unmet from last two inspections. Risk assessments that underpin risks service users undertake and are exposed to must be developed. These must be reviewed six monthly or sooner if needs change. Unmet from last inspection. Clinical risks service users present must be fully assessed, and control DS0000016946.V296770.R01.S.doc Timescale for action 01/09/06 2. YA6 15(1) 12(2) 12(2) 01/09/06 3. YA6 01/08/06 4. YA7 12(2) 16(2)(m,n) 13(4)(a-c) 01/08/06 5. YA9 01/09/06 6. YA9 13(4)(a-c) 01/08/06 Woodridge Road Version 5.2 Page 26 7. YA10 8. 9. YA11 YA17 10. YA18 11. YA19 12. YA19 13. YA19 14. YA19 15. YA20 16. YA20 17. YA23 measures to underpin these developed. 23(1)(a) The home-owner must provide an 12(4)(a) action plan with timescales detailing how adequate space for confidential meetings and conversations to take place will be provided 16(2)(m-n) Service users must be provided with opportunities to undertake personal development 17(2) Unmet from last two inspections. Sch4 The home must ensure service 13 users are offered a nutritious 16(2) balanced diet, reflective of their 1 individual needs. 12(1)(a) Unmet from last two inspections. 12(2) Service users plans must detail how personal care is to be delivered. 12(1)(a) Service users needs regards 13(1)(b) weight management, bowel care, night needs, continence and epilepsy must be planned for, and effective monitoring undertaken and recorded. 12(1)(a) Unmet from last two inspections. 13(1)(b) Evidence that service users have received all required follow up to healthcare must be available. 12(1)(a) Difficult to manage behaviour must 13(6) be underpinned with a strategy, and effective monitoring of this must be undertaken. 12(1)(a) Unmet from the last inspection. Healthcare needs must be planned and monitored. A record of this must be maintained. 13(2) Unmet from last two inspections. All staff must receive accredited training in the safe handling and storage of medication. 13(2) Unmet from the last inspection. All medication prescribed and available in the home must be listed on the MAR. 13(6) Unmet from last two inspections. The manager must ensure all DS0000016946.V296770.R01.S.doc 01/09/06 01/10/06 01/08/06 01/09/06 01/09/06 01/08/06 01/08/06 01/08/06 01/10/06 01/08/06 01/07/06 Page 27 Woodridge Road Version 5.2 18. YA23 13(6) 19. YA23 13(6) 20. YA23 13(6) 21. YA24 23(2)(b) 3(3) 22. 23. YA26 YA24 YA26 16(2)(b) 23(2)(b) 23(2)(b,d) 24. YA30 13(3) 25. YA30 16(2)(k) 13(3) 26. 27. 28. YA30 YA30 YA33 13(3) 13(3) 18(1)(a) possible action to keep service users safe from harm, or risk of harm is undertaken. Unmet from last two inspections. Permission must be given from the service user or appointee before any deduction is made from service users monies. Money paid by service users towards meals and leisure must be reviewed, and money spent refunded where required. A review of the homes security must be undertaken, to ensure service users and their possessions are safe within the home. Unmet from last two inspections. Kitchen doors, drawer fronts, and shelves inside cupboards must be maintained in a good state of repair. Furniture in communal areas and bedrooms of the home, must be maintained in good condition CP bedroom unmet from the last inspection. The bedroom of CP and ** must be redecorated. Staff must be provided with clear guidance and training regards infection control when cleansing faecal accidents. Unmet from last two inspections. A satisfactory level of cleanliness must be maintained throughout the home (Including the cleansing of bath/shower chairs) Odour control must be achieved in all areas. Unmet from last two inspections. Dry food goods must be stored in an airtight way. Food hygiene practice must be improved to ensure food is used or discarded by the best before date. Unmet from last inspection. The number of staff provided must be reviewed, and action taken to DS0000016946.V296770.R01.S.doc 01/08/06 01/08/06 01/07/06 01/10/06 01/10/06 01/10/06 01/07/06 01/07/06 01/07/06 01/07/06 01/08/06 Woodridge Road Version 5.2 Page 28 29. YA35 18(1)(a) 19(5)(b) 30. YA34 19 Sch2 31. 32. YA39 YA41 24 26 33. 34. YA41 YA42 17 13(4)(b-c) 35. YA42 23(4)(a) 36. YA42 13(4)(c) ensure this safely meets service users needs. Unmet from last two inspections. The home must ensure persons employed to work at the home receive training appropriate to the work they are to perform. Training records must be available for inspection. Unmet from last two inspections. The manager must ensure all staff files contain: - Documented evidence of qualifications. - Two written references - Evidence that the person is physically and mentally fit for the work - A completed CRB check. - Two forms of Identification - Evidence of their fitness for the job. The provider must ensure there is an effective model of Quality assurance in use in the home. The quality of regulation 26 visits must be improved, to ensure they fully assess the situation in the home. Record keeping must be reviewed and improved. Not assessed at this inspection. Risk assessments must be developed for food and the premises. Confirmation that all actions identified in the fire risk assessment have been undertaken must be provided. Confirmation that Legionella screening has been undertaken, and that the result was satisfactory must be obtained. 01/08/06 01/08/06 01/08/06 01/08/06 01/08/06 01/08/06 01/08/06 01/08/06 Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 29 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. 4. Refer to Standard YA9 YA12 YA18 YA41 Good Practice Recommendations It is recommended that risk assessments be stored with care plans or that a clear signpost to them be included in the care notes. It is recommended that the purpose and benefit of activities be established in the service users plan. It is recommended that service users needs regarding their sexuality be further explored and recorded, to ensure these are met. It is recommended that files of records be organised chronologically or according to the index order. Woodridge Road DS0000016946.V296770.R01.S.doc Version 5.2 Page 30 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. 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