Inspection on 19/12/05 for Woodridge Road

This inspection was carried out on 19th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 39 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 01/06/06

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 19th December 2005 08:40 Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 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.V274098.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 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.V274098.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodridge Road Address 6a Woodridge Road Aston Birmingham West Midlands B6 6LN 0121 240 4480 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.V274098.R01.S.doc Version 5.1 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. 2nd August 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, which 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 registered manager. Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One CSCI inspector undertook this inspector with Mandy Warner, an expert by experience (Exbyex). The inspection was undertaken over the morning of one day. Information used in the report was collected by talking with the people who live in the home (as far as possible) and observing the care and support they receive. The records of care for two people were looked at, and records about staffing and health and safety. The shared areas of the home were looked at and one person said it was alright to look in their room. The inspection did not identify that many of the previously made requirements had been met. The inspection team were concerned about the way one of the service users spoke to the other three women who live in the home, as at times this was very offensive. The inspection identified numerous concerns, and these have been raised with the home in a letter of serious concern. The inspection team extend their thanks to everyone who helped with this inspection. What the service does well: 6a Woodridge Road is very homely, and when you enter the home it looks really nice. The home had been decorated for Christmas and looked festive. The women all have their own room, and these contained the things important to them. The women all looked well dressed, and it appeared they had chosen a style of dress they liked. There was plenty of food in stock. This was of a good quality, and varied. Staff help people stay in touch with their family and friends. This included organising a party at the weekend prior to the inspection. The Exbyex established that all the women have their own bank account, and that they are supported to spend money on things important to them. Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The exbyex said she struggled to find positive things to say about the home, as her observations during the visit were not positive. She stated she was pleased not to have to live in the home, and that the women did not really have a life, just an existence. As the inspection team entered the home there was a strong, unpleasant smell. This must be removed. The number of staff was not adequate to meet the needs of the people who live in the home. Two people were able to go out, but this was because a student nurse supported the activity. The student nurse should be in excess to the staff needed. The exbyex said,” I don’t think staffing levels are acceptable because of health and safety and for protection from abuse. I think as a matter of urgency staffing levels must be addressed.” The records of recruitment did not show that all the required documents had been obtained for staff before they started work in the home. The medication records did not show that staff were checking the medicine, as they should when it arrives in the home, or that medication was being given as prescribed by the GP. The records about peoples needs did not show how all their care needs had been planed for, or were being met. This included serious conditions like epilepsy, eating and drinking and pressure care. The plans do not show how staff have talked to the women about what to include. None of the plan is written in a way people living in the home could access. One of the women who live in the home is regularly very rude to the other three people who live in the home. The language used is offensive. The way the three women are protected from the effects of this, and the way the service user is supported regarding this were not adequate. The exbyex raised Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 Page 7 concern for the service users who have to listen to this, and the service user who seemed very ”fed up” The exbyex observed service user request a cup of coffee and be given a glass of squash. The staff offered no explanation for this. The inspection team found this disrespectful of the service users wishes. The needs of the people who live at 6A Woodridge road vary. The inspection team were not confidant that one of the service needs were being well met in this home, or that it was a suitable place for her to live. 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.V274098.R01.S.doc Version 5.1 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.V274098.R01.S.doc Version 5.1 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 Standards not assessed at this inspection. EVIDENCE: This home accommodates four service users. There are no residential vacancies, and there had been no new admissions since the last inspection. Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 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, 9 Service users health care needs and risks are not well planned for or delivered which could place service users at risk of harm, or result in needs being unmet. Plans to develop plans that are more person centred have been commenced, but to date care documents do not evidence service user consultation. EVIDENCE: The plans of two service users were assessed. The plans did not adequately detail how service users needs were to be met, or evidence any sign of consultation with them or their family. The manager informed the inspector that she has commenced person centred planning, but that much further work is required to develop these. The culture in the home was not observed to promote decision making opportunities. Examples such as a member of staff providing drinks and lunch, but with no reference to the choice or preference of the service users was observed. The exbyex explored communication with service users with one member of staff. Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 Page 11 The exbyex commented that she did not observe any staff use tools to aid communication, and that generally she did not think good communication was observed during the visit. The service users are at risk from injury or psychological abuse from each other. The inspection team observed three service users being verbally abused by another service user, and records on file showed physical altercations in which people had been assaulted had occurred. It was not evident that these risks had been effectively assessed or strategies put in place to manage them. Clinical risks such as dysphasia and risk of pressure injury had been identified by risk assessment. The action taken by staff to control these risks had not been developed into a support plan. Risk assessments are stored separately to the care plans. A previous recommendation that these be stored together or a clear signposting system established is unmet. Many of the risk assessments assessed were pro-forma’s. These had not been adequately developed to underpin the specific risk to this service user in this home. Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 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, 17 Opportunities to undertake leisure both in the home and community are provided. These opportunities are not frequent enough to ensure service users are offered an interesting and varied lifestyle. Service users are well supported to maintain contact with their family and friends. Service users are offered a varied and nutritious diet. EVIDENCE: The opportunities provided to two service users to undertake leisure and developmental activities were assessed. The inspector read some care records that showed service users had been supported to undertake household tasks such as laundry and clearing crockery. This activity had not been included in the service users plan. In the eighteen days sampled one of the service users had been out of the home on three occasions. One of these was listed as local shops, the other two activities as “drive out”. The second service user had been out of the home on one occasion. Most other entries stated, “Walked around the home”, “Listened to music”, “Watched TV and chatted with staff”, and “manicure.” All members Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 Page 13 of the inspection team raised concern about the limited opportunities available for people to engage in. The daily records identified that service users are supported to maintain contact with their family, and this included at a party hosted by the home in the weekend prior to inspection. All members of the inspection team considered this to be an area of good practice. The stock of food available was plentiful and included a range of fresh and good quality products. The variety of food served was not as varied as that planned on the menu. Staff must ensure they record meals eaten in adequate detail to establish if fruit, salad and vegetables are offered and served. The food eaten was not all suitable for the needs of service users accommodated, some of whom are recorded to have dysphasia. It has been required specialist advice be sought regarding this from the speech and language therapy team. The menu details a choice of two meals each day. The inspector did not evidence that this choice was offered in practice. At lunchtime service users all were served the same meal, and no opportunity to chose an alternative was provided. Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 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 Service users are supported to undertake personal care to a good standard. Service users have healthcare needs, which were not well planned for. Evidence that routine health screening and monitoring had been undertaken was not available. This could result in healthcare needs being unmet. Medication management of products not blister packed did not evidence service users had received the right medicine at the right time. Records of receipt and disposal were not robust. EVIDENCE: The inspection team met with all four of the service users accommodated at the home. It was apparent all the women had been supported to undertake personal care and they appeared well dressed, and very individual in their style. The service users healthcare needs were assessed. The plans were all overdue for a six-month review. Appointments with the chiropodist had not been recorded since July 2005. An appointment with the dentist was recorded in two files in September 2004. It was recorded the dentist wished to review the service user after one year. It was not evident this appointment had been made or offered. One service user was assessed to be at risk of pressure injury. It was not evident from the plan what action had been taken to manage this risk. Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 Page 15 One record made reported that the person had a broken area of skin in February 2005 but records did not show support was sought at this time from the district nurses. Weight records were on a chart, with no record of the year they relate to. The last entries made were in July and May. Even if this record refers to 2005 it is not evident this need has been well met. One service user tracked was recorded to have dysphasia. It was reported a referral has been made to the speech and language therapy team for assessment. Two service users have some difficult to manage behaviour that has included physical assaults on other service users, and verbal abuse to staff and other service users. Evidence of how this is being monitored or that an effective strategy to address this need had been developed was not available. One service user with epilepsy was tracked. The inspector found no plan of care regarding this area of need in the service users file. Medication management was poor. Records did not show that medication was checked when received into the home. Three medicines that are not blister packed were audited. None of these medicines tallied with records of receipt or administration, which did not confirm that service users had received the right medication at the right time. Protocols for all the as required (PRN) medicines were not available. Some medicines were available in stock, but not listed on the medication administration record (MAR) Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 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): 23 Some service users present a risk to themselves and to each other. These risks are not well planned or managed, and records of physical and psychological harm were available in the home. EVIDENCE: Two service users are known to have a difficult relationship. A plan to underpin this was available, but not adequate to underpin the known risks. The behaviour management guidelines instructed staff to intervene in the event of verbal aggression, and to “Ask the service user to apologise and make friends.” The plan makes no allowance for the other two service users who are verbally assaulted. In one file a, ”Challenges to the service” assessment had been undertaken. This identified communication as a possible trigger for challenging behaviour. The care plan regards communication was very poor, and gave staff no guidance on how to effectively communicate with the person, or tools that would aid this. During the visit members of the inspection team sat in the lounge and heard service users being swore at, shouted at, and treated in a derogatory way by another of the service users. Records also showed an incident in November where one service user struck another. The inspection team did not evidence that service users safety was being ensured. Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 The home meets the needs of service users in a domestic and homely way. The cleanliness and way odour is managed must improve. EVIDENCE: 6a Woodridge Road is a domestic and homely property. Staff and service users had trimmed the house with Christmas decorations and it looked very festive. The inspection team looked in all the communal areas of the home and in one service users room. The exbyex said, “The home was quite small but clean and tidy.” The home would have benefited from a vacuum in all areas. A strong offensive odour was evident as you entered the home. The kitchen worktop had been replaced and appears improved. The kitchen cupboards and internal shelves continue to require attention or replacement. The cleanliness of cupboards and drawers required attention. The COSHH cupboards in the kitchen and laundry were unlocked. Doors to these rooms were both open. This has been identified in the past two inspection reports. The water from the shower in the shower room delivered hot water at 47.3°c. An immediate requirement that this be reduced was made. Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 Page 18 The assisted bath hi-lo facility was broken, and the screws attaching the bath chair to the frame were observed to be loose. This must be urgently repaired. Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 36 The number of staff is not adequate to enable service users to access the community on a regular basis, or to be supported with interesting activities within the home. The two staff files assessed did not evidence that service users were protected by robust recruitment practice. Staff are supported by regular detailed supervisions. EVIDENCE: The number of staff on duty is usually two in the morning and afternoon shift, and one waking staff at night. The inspector did not find this to be adequate to enable service users to go out into the community, as all require 1-1 support when out of the home. Staff work in a multi-role capacity and during the inspection one staff and a student nurse supported two service users out of the home. The remaining staff was pre-dominantly occupied with housework, meal preparation and answering the phone. At one point this was observed to put one service user at risk of harm, when she transferred herself from the wheelchair to armchair. During the manoeuvre she caught her foot, which nearly resulted in her falling. No staff were close to by to observe or support. One service user called out three times for staff support to use the toilet. It was of concern staff did not respond sooner, and that more dignified ways of requesting assistance had not been provided. Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 Page 20 The inspection team observed staff request one service user undertake exercises in the lounge. This did not seem sensitive to the feelings of the service user, undertaking these in the presence of visitors. The recruitment files of two staff were assessed. These did not contain references or any form of identification. It was not evident that service users were being protected by robust recruitment practices. Staff had both been supervised regularly, and the records available showed this had been undertaken to a good standard. Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 42 The home has a permanent manager who shows commitment to the service users and development of the home. The health and safety of service users, staff and visitors is protected by formal servicing but not by routine tests undertaken by staff in the home EVIDENCE: The home has a permanent manager who is registered with the CSCI. She demonstrated a clear commitment to the needs of the service users and the development of the home. The inspection team did not evidence that this was a well run home, or that outcomes for service users were positive. The records of service for the fire alarm, electrical, gas and lifting equipment were up to date. Staff had not undertaken the testing of the fire alarm, emergency lighting, food core temperatures or fridge/freezer temperatures with the required frequency. Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 Page 22 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 X 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 X 33 1 34 1 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 1 X LIFESTYLES Standard No Score 11 1 12 1 13 1 14 1 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 1 X 2 X X X X 1 X Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 Page 23 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 Service users plans must evidence their aspirations and goals and how these are to be met. Unmet from last inspection. Service users plans must evidence consultation with the service user or their representative. Unmet from last inspection. Service users must be offered opportunity to decision make regarding their care and lifestyle. Unmet from last inspection. 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 measures to underpin these developed. Timescale for action 01/03/06 2. YA6 15(1) 12(2) 01/03/06 3. YA7YA8 12(2) 16(2)(m,n) 01/03/06 4. YA9 13(4)(a-c) 01/03/06 5. YA9 13(4)(a-c) 01/03/06 Woodridge Road DS0000016946.V274098.R01.S.doc Version 5.1 Page 24 6. YA14 16(2)(m,n) 7. YA17 17(2) Sch 4 13 17(2) Sch4 13 16(2)1 12(1)(a) 12(2) 12(1)(a) 8. YA17 9. YA18 10. YA19 11. YA19 16(2)(i) 12(1)(a) 15 12(1)(a) 13(1)(b) 12. YA19 Service users must have opportunity to undertake activities of their choice. Unmet from last inspection. The record of food eaten must be in sufficient detail to establish the nutritional value of the diet offered. Unmet from last inspection. The home must ensure service users are offered a nutritious balanced diet, reflective of their individual needs. Unmet from last inspection. Service users plans must detail how personal care is to be delivered. Unmet from last inspection. Care plans must be reviewed at least six monthly, or sooner if service users needs change. Service users with specific dietary needs or at nutritional risk must have a care plan regards nutrition. Unmet from last inspection. Evidence that service users have received all required follow up to healthcare must be available. Unmet from last inspection. Eating and drinking guidelines must be available for service users with dysphasia. 01/03/06 01/03/06 01/03/06 01/03/06 01/03/06 01/03/06 01/03/06 13. YA19 12(1a) 13(1b) 13(4c) 01/03/06 14. YA19 12(1)(a) Refferal must be made to the Speech and Language team for service users with dysphasia. Unmet from last inspection. Service users must be 27/01/06 offered access to all healthcare appointments, DS0000016946.V274098.R01.S.doc Version 5.1 Page 25 Woodridge Road 15. YA19 12(1)(a) 16. YA20 13(2) 17. YA20 13(2) 18. YA20 13(2) 19. 20. YA20 YA23 13(2) 13(6) 21. YA23 13(6) 22. YA24 23(2)(b) 3(3) 23 24. YA24 YA26 23(2)(b) 23(2)(b,d) and a record of these maintained. Healthcare needs must be planned and monitored. A record of this must be maintained. All medication brought in to the home must be accounted for. Records must evidence how medicines are disposed of. Unmet from last inspection. A system of auditing non blister packed medicines must be developed and implimented. Unmet from last inspection. All staff must receive accredited training in the safe handling and storage of medication. Unmet from last inspection. All medication prescribed and available in the home must be listed on the MAR. The manager must ensure all possible action to keep service users safe from harm, or risk of harm is undertaken. Unmet from last inspection. Permission must be given from the service user or appointee before any deduction is made from service users monies. Unmet from last inspection. Kitchen doors, drawer fronts, and shelves inside cupboards must be maintained in a good state of repair. Unmet from last inspection. The assisted bath must be repaired and returned to full operation. The bedroom of CP must be redecorated. DS0000016946.V274098.R01.S.doc 27/01/06 27/01/06 27/01/06 01/04/06 27/01/06 27/01/06 01/03/06 01/03/06 27/01/06 01/04/06 Page 26 Woodridge Road Version 5.1 25. 26. YA27 YA30 23(2)b 23(2)p 16(2)k 16(2)(k) 13(3) 27. 28. YA30 YA30 13(3) 13(3) 29. 30. YA30 YA33 13(3) 18(1)(a) 31. YA35 18(1)(a) 19(5)(b) The odour in the shower room must be effectively managed. 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 inspection. Dry food goods must be stored in an airtight way. Unmet from last inspection. Fridge and freezer temperatures must be taken and recorded daily. Unmet from last inspection. Soap and towels must be provided for staff use in the laundry. The number of staff provided must be reviewed, and action taken to ensure this safely meets service users needs. Unmet from last inspection. Records to evidence this not available 27/01/06 27/01/06 27/01/06 27/01/06 27/01/06 01/02/06 01/03/06 32. YA34 19 Sch 2 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. The manager must ensure 01/02/06 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. Unmet from last inspection. DS0000016946.V274098.R01.S.doc Version 5.1 Page 27 Woodridge Road 33. YA42 13(4)(b-c) 34. YA30YA42 13(4)(b-c) 35. 36. YA42YA24 YA42 13(4)(b-c) 13(4)(b-c) Risk assessments must be developed for food and the premises. Unmet from last inspection. Al substances hazardous to health must be stored securely at all times. Unmet from last inspection. The shower water temperature must be reduced to 43°c. Health and safety tests to include the fire alarm, emergency lighting, fridge temperatures and food core temperatures must be undertaken and recorded as required. 01/04/06 27/01/06 27/01/06 27/01/06 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. 5. 6. Refer to Standard YA9 YA12 YA11 YA18 YA41 YA42 YA28 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. It is recommended that surplus items contained in the shed be discarded if no longer required. It is recommended that office space for private meetings be provided. Woodridge Road DS0000016946.V274098.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 Woodridge Road DS0000016946.V274098.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. 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!