Inspection on 02/08/05 for Woodridge Road

This inspection was carried out on 2nd August 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 38 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 19/12/05

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 B6 6LN Lead Inspector Alison Ridge Unannounced 2 August 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodridge Road Address 6a Woodridge Road Aston Birmingham B6 6LN 0121 240 4480 0121 240 4480 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) Focus Futures Ltd Margaret Judith Oakley Care Home 4 Category(ies) of Younger Adults, Learning Disability [4] registration, with number of places Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. 2. A maximum of 4 service users may be accommodated for reasons of learning disability 3. 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. Date of last inspection 7 January 2005 Brief Description of the Service: 6A Woodridge is a modern bungalow, situated in a quiet culdesac 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 E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this visit over one day. During the visit she was pleased to meet all four of the women accommodated at the home. The inspector also met staff on both the morning and afternoon shifts. Information used in this report was collected by talking with service users, observing the care and support they receive, and informally talking with staff on duty. Records regarding care, staffing and health and safety were inspected. A full tour of the premises was undertaken. What the service does well: What has improved since the last inspection? Five of the fourteen requirements made in January had been met. The home has got better at food storage, keeping records secure, talking to people who live in the home properly and training staff when they start they job. Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 8 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 standard(s) x None of these standards were assessed. EVIDENCE: The home has a stable service user group. There had been no new admissions and there were no residential vacancies. Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 9 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 standard(s) 6, 7, 8, 9, 10 Service users needs and risks are not well planned or delivered. Service users are not consulted regarding their lifestyle or preferences. EVIDENCE: The plans of two service users were assessed. The senior carer on duty informed the inspector that Good Life plans would be developed with the service users. At present the plans available do not contain any information about life goals, or show consultation with the service user or their representative. The service users plans all started with a profile/pen picture of the service user, which gave the reader a good introduction to the person. The manager must ensure information in these is consistent with facts, and the rest of the information. Some inconsistencies, including date of birth were observed. The inspector did not witness many opportunities for service users to decision make. The inspector challenged the entry about decision-making made in the notes of the two service users files sampled. Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 10 These stated the person was “unable to make informed decisions”. There was no evidence as to how this had been established, or ways in which the home could promote service users autonomy and decision-making. Service users meetings are not held, and evidence as to how the service users are consulted and kept informed about life in the home was not available. During the inspection service users were not observed to take part in household tasks, although evidence people had been included in laundry, gardening, and cake baking was available in the daily notes. Risk assessments for service users had all been subject to review. It is recommended that personal risk assessments be stored with active care information, or at least a clear sign post to them be made in the care notes. Risks were identified during the inspection from incident reports, from observation and care notes that had not been underpinned with risk assessments. These included eating and drinking, epilepsy; falls and the risks service users pose to each other. Care notes were all securely stored at the time of inspection. Staff interactions, and the handover were undertaken sensitively. Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 11 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 standard(s) 11, 12, 13, 14, 17 Opportunities to undertake leisure and developmental activities are provided. There was not evidence that these were the choice of or of benefit to service users. EVIDENCE: The activities offered to two service users over a two-week period were assessed. Service users had been supported to undertake activities in the community approximately every other day. The activities offered were varied, but it could not be established how they had been chosen upon, or what the benefit or purpose to the service user was. It is recommended this be explored, possibly as part of the Good Life planning, and included in the service users plan. The inspection did not identify how service users were being encouraged or enabled to develop new skills. The staff had organised a number of in house activities that included massage, nail care/beauty, games, baking, and music and dancing. Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 12 Several organised activities were undertaken during the inspection. One service user who was unable to verbally communicate demonstrated very clearly that she wished to go out for a walk. She repeatedly got her coat, and shoes. Staffing during the morning was inadequate to support this activity. The service user was able to go out, after the inspector prompted staff during the hand-over period. Two of the service users were preparing for a holiday, over the weekend following the inspection. The amount and range of food available was good, and very varied. The lunchtime meal was nutritious. Fresh fruit, vegetables and salad were available. The inspector noted that most meat available was in whole cuts, and not processed which was positive to see. The record of food eaten did not evidence that service users are offered or eat fruit and vegetables each day. The record of food eaten must be specific and avoid statements such as “Brunch” which doesn’t enable the reader to establish what was actually eaten. This must be explored with staff and improved upon. Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 13 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 standard(s) 18, 19, 20 Service users personal care needs appeared well met. Some healthcare needs are well met, others require better planning and recording to evidence service users are receiving all care and support required. EVIDENCE: The service users the inspector met with were all well presented, and it was apparent they had been supported with personal care. Service users were sensitively supported throughout the day to freshen up, and change their clothes as was required. The plans regarding personal care did not provide specific information on how to support the service users. The plans were mainly of a tick box variety. It was ticked that someone required” full support” or were “independent”. One of the plans sampled regarding incontinence simply stated,” She must be toileted” with no reference as to how, the persons preference, frequency, or products required. The daily notes continue to require development to show what care and support was offered/delivered. The inspector spoke with staff about the entries made regarding service users sexuality needs. Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 14 A simple statement stating that the person is or isn’t sexually active, fails to reflect the much broader issues surrounding sexuality. It is recommended this be further explored. The service users files sampled evidenced that people had been supported to attend all routine health screening. Service users had been regularly weighed, and support from dietetic services obtained. The staff support service users to attend a local walking group. The service users needs regarding weight gain or weight loss must be underpinned with a care plan. It was positive to hear form the senior that appointments to review medicines are being sought. The records evidenced that staff respond to service users needs, and seek medical appointments as required. The area, which must improve, is evidencing that the appointment was followed up, and that any required treatment was obtained. One risk assessment sampled identified that the person has dysphasia. One staff described another service user regurgitating food. It wasn’t apparent that referrals had been made to Speech and Language therapy regarding this, or that an eating and drinking plan had been developed. The inspector observed two service users supported at mealtime in a very structured way. This was not underpinned with a care plan or strategy. The medication is administered from a monitored dosage system. The storage was clean and organised. A record of medication being received into the home had not been made. The staff had not checked the received medicines against the FP10 prescription. It was not possible to confirm if non-blister packed medicines had been given as prescribed. The inspector found an inadequate stock of Fybogel to be available for one service user. Additional stocks were requested. It appears that staff had given in excess of the prescribed dose, and it has been required this be further explored. A box of dressings was available for one service user. The care plan did not evidence if these are in use, or where they are to be applied. This must be explored. As required medicine was not written on the MAR sheets. Protocols to underpin the use of as required products must be available, individual to each person, and kept under review. The senior reported that one staff had achieved the accredited medicines training. All staff must work towards this. Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 15 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 standard(s) 22, 23 The operation of the home does not ensure service users are protected from harm or risk of harm. EVIDENCE: No complaints have been made to the CSCI or direct to the home. This was not further assessed. The inspector observed some interactions between service users that were not positive. This included one service user name calling other people names, and swearing at them. The incident reports identify a number of occasions where one service user has harmed another person. These risks had not been assessed. The home did not have any clear strategy for keeping people safe, and the inspector identified long periods where service users were vulnerable to each other, as no direct supervision by staff was available. The inspector raised concern regards one service users money. A large sum had been withdrawn five days prior to the inspection. This had not been entered on to the homes records. This money could not have been accurately audited. The manager must ensure monies are all accounted for and recorded. It was of concern that the requirement regarding payment by service users towards the home vehicle had not been addressed. This must be undertaken with urgency. Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 16 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 standard(s) 24, 25, 26, 27, 28, 29, 30 The home meets the needs of the service users in a domestic and homely way. The cleanliness of the home must improve. EVIDENCE: The inspector undertook a tour of the home. 6A Woodridge is domestic in size and very homely. The lounge furniture was of a good quality and suited the needs of the people accommodated. Some minor damage to the décor was noted, in communal areas. Each service user has a single bedroom. These were personalised with photos and important items for each person. Thought had obviously been given to obtaining suitable beds, according the service users needs. One-service users rooms had significantly damaged wallpaper, which requires redecoration. The safety rails on one service users bed were broken. It was required these be removed or repaired, as they present a sharp hazard. Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 17 The inspector noted that some door and drawer fronts in the kitchen were becoming loose. The shelves inside cupboards were splitting and peeling. The kitchen must be reviewed, and action to ensure it is well maintained, and hygiene maintained. Minor repairs including handles working loose on wardrobes and vanity cupboards, bulbs in overhead lights that require replacing, and some minor damage to the décor and plaster were noted. Confirmation these have been rectified is required. The home has a large assisted bathroom, and a shower room. The bathroom was well presented. The shower room had an offensive odour, and it was noted the extractor fan was not in operation. This must be repaired. The home has a comfortable lounge, and dining room. The home has no staff office, and the dining room, was taken up for several periods of the day with staff completing handover and paper work. The home has a pleasant garden, and the covered Gazebo provides a comfortable seating area. The home has no venue to undertake meetings or reviews. Confidential conversations and supervisions also have to be undertaken in communal areas. Floors in the service users bedrooms required hoovering. The inspector identified some instances where incontinence had not been well cleaned, and residue remained on the floor or, bed frame. Food Hygiene was generally good. Some dry goods required storage in airtight containers. The fridge freezer temperatures must be taken daily. This was outstanding from 29/7/05. The cupboard and drawer fronts must be regularly cleaned. The inspector noted much of the crockery is chipped. This must be replaced. Soap and towels must be provided in the laundry for use by staff that has handled laundry. The bath and shower chair both had residue from previous baths and showers on them. These must be routinely cleaned. Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35, 36 Staff had a positive regard for service users, but recruitment, training and supervision does not ensure service users safety and welfare or promote the consistent meeting of their needs. EVIDENCE: The inspector did not evidence that adequate staff were available at the time of inspection. Two carers were provided on both the early and late shift, which did not enable service users to undertake any community activity, although this was the expressed wish of one person. The rota identified that staffing was regularly at this ratio, although on some days it did increase to four, with the support of a student nurse. The inspector identified that some peoples risk assessments identified they require 2-1 staffing when out. The current ratios would make this very difficult, and the record of activities identifies that this staff ratio would not have been achieved on all the activities recorded. This area must be reviewed. The senior carer reported that records of training were not yet available. This task has been assigned to one staff member for action. The manager must ensure that all staff have received the required mandatory and service user specific courses. Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 19 The records of recruitment for four staff were assessed. No file contained the full records required. Significant deficits including the absence of references, and identification were noted. This must be urgently attended to. One staff that had moved from one trust home to another had no evidence of being inducted to the home, and the service users accommodated. Two of the four staff files showed no sign of supervision. The other two files showed regular supervision. This was with the required frequency to meet the bi-monthly target, and in good detail, including performance, training and personal concerns. Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 41, 42 The management and operation of the home is fair. It must improve to ensure outcomes for service users are consistently met. EVIDENCE: The home has a registered manager. There were many signs that the home is well run, and organised to the benefit of the service users accommodated. Specific concerns identified during the inspection, and previously unmet requirements must be actioned with urgency. The inspector was unable to establish if the manager had undertaken training to supplement the NVQ level 4 as has been previously required. The records were all available for inspection. It is recommended that thought be given to ensuring the order of files is logical, and follows the index or chronological order. The home has a current certificate of registration and liability insurance. Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 21 Regulation 26 visits are undertaken by the trust, but evidence that Focus Futures visits the home on a regular basis was not available. The fire alarm and emergency lights had been tested as is required. The fire system had been serviced. Risk assessments for the premises and for food require development. The shed appeared to be very full. It is recommended this be sorted and items no longer required discarded. Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score x 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 1 1 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 2 2 x 1 Standard No 11 12 13 14 15 16 17 3 2 2 2 x x 2 Standard No 31 32 33 34 35 36 Score x x 2 1 1 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodridge Road Score 1 2 1 x Standard No 37 38 39 40 41 42 43 Score 2 x x x 2 2 x E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 23 YES 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 YA6 Regulation 15(1) Requirement Timescale for action 1/10/05 2. YA6 3. 4. 5. YA6 YA8 YA9 6. 7. YA14 YA17 8. YA17 Service users plans must evidence their aspirations and goals and how these are to be met. 15(1)and Service users plans must 12(2) evidence consultation with the service user or their representative. 12(1)(a) Information contained in service users plans must be correct and consistent. 12(2) Service users must be offered 16(2)(mopportunity to decision make n) regarding their care and lifestyle. 13(4)(a-c) 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. 16(2)(mService users must have n) opportunity to undertake activities of their choice. 17(2) The record of food eaten must Schedule be in sufficent detail to establish 4 13 the nutritional value of the diet offered. 17(2) The home must ensure service Schedule users are offered a nutricious 4 13 and balanced diet, reflective of their E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc 1/10/05 1/9/05 1/9/05 1/10/05 1/9/05 1/9/05 1/9/05 Woodridge Road Version 1.40 Page 24 16(2)(i) 9. 10. 11. YA18 YA18 YA19 12(1)(a)1 2(2) individual needs. 1/10/05 1/9/05 1/9/05 12. 13. YA19 YA19 14. YA20 Service users plans must detail how personal care is to be delivered. 12(1)(a) A full record of the personal care offered and delivered must be maintained. 16(2)(i) Service users with specific 12(1)(a) dietary needs or at nutritional and 15 risk must have a careplan regards nutrition. 12(1)(a) Evidence that service users have and received all required follow up to 13(1)(b) healthcare must be available. 12(1)(a),1 Eating and drinking guidelines 3(1)(b) must be available for service and users with dysphasia. 13(4)(c ) Refferal must be made to the Speech and Language team for service users with dysphasia. 13(2) All medication brought in to the home must be accounted for. Records must evidence how medicines are disposed of. 13(2) 13(2) 13(2) 13(2) 13(6) A system of auditting non blister packed medicines must be developed and implimented. Medicines must be administered as per prescription. Protocols must be developed for all As Required medicines. All staff must receive accreditted training in the safe handling and storage of medication. The manager must ensure all possible action to keep service users safe from harm, or risk of harm is undertaken. Systems and practice regarding service users money must be reviewed to ensure they are robust and protect service users interests. Permission must be given from the service user or appointee 1/9/05 22/8/05 15. 16. 17. 18. 19. YA20 YA20 YA20 YA20 YA23 Unmet from previous inspection. 22/8/05 1/9/05 22/8/05 1/9/05 1/11/05 22/8/05 20. YA23 13(6) 29/8/05 21. YA23 13(6) Unmet from Page 25 Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 before any deduction is made from service users monies. 22. YA24 23(2)(b) and 13(3) 23(2)(b) Kitchen doors, drawer fronts, and shelves inside cupboards must be maintained in a good state of repair. Minor repairs including loose door handles, replacing light bulbs, and repairing minor damage to the and plaster must be undertaken. The bedroom of CP must be redecorated. One set of broken bed safety rails must be repaired, replaced or removed, as required. The shower room extractor fan must be returned to operation. 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. Dry food goods must be stored in an airtight way. Fridge and freezer temperatures must be taken and recorded daily. Crockery must be replaced if it is chipped or broken. 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. Records to evidence this not available The home must ensure persons employed to work at the home receive training appropriate to Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc previous inspection. 1/10/05 1/10/05 23. YA24 1/9/05 24. 25. 26. YA26 YA26 YA27 27. YA30 23(2)(b) and (d) 23(2)(b) and 13(4)(c ) 23(2)(b) and 23(2)(p)a nd 16(2)(k) 16(2)(k) and 13(3) 1/10/05 22/8/05 22/8/05 1/9/05 28. 29. 30. 31. 32. YA30 YA30 YA30 YA30 YA33 13(3) 13(3) 13(3)(4)( c) 13(3) 18(1)(a) 1/9/05 22/8/05 1/9/05 22/8/05 1/9/05 33. YA35 18(1)(a) and 19(5)(b) Unmet from previous inspection. 1/10/05 Page 26 Version 1.40 34. YA34 35. 36. YA36 YA37 the work they are to perform. Training records must be available for inspection. 19 The manager must ensure all Schedule staff files contain , 2 Documented evidence of qualifications. Two written references Evidence that the person is physically and mentally fit for the work A completed CRB check 18(2) All staff must receive supervision at least six times each year. 9(2)(b)(1) Records to evidence this not available The registered manager has Manager has qualifications at level 4 NVQ in both management and care BY 2005. The registered manager undertakes periodic training and development to meet TOPPS specifications, to maintain and update her knowledge, skills and competence whilst managing the home. 13(4)(b-c) Risk assessments must be developed for food and the premises. 13(4)(b-c) All substances hazardous to health must be stored securely at all times. Unmet from previous inspection. 1/9/05 1/10/05 Unmet from previous inspection. Manager to provide evidence with response to report. 37. 38. YA42 YA30 1/10/05 Unmet from previous inspection. 22/8/05 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. Refer to Standard YA9 Good Practice Recommendations It is recommended that risk assessments be stored with care plans or that a clear signpost to them be included in E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 27 Woodridge Road 2. 3. 4. 5. 6. YA 11 and 12 YA 18 YA41 YA42 YA28 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 E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 Page 28 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 Woodridge Road E54 S16946 Woodridge Road V242714 020805 Stage 4 Final.doc Version 1.40 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. 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