Inspection on 08/01/09 for Woodside

This inspection was carried out on 8th January 2009.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodside 19/02/08

Woodside 31/08/07

Woodside 25/07/06

Woodside 06/10/05

Woodside 23/05/05

Woodside 12/10/04

Woodside 06/07/04

Woodside 10/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Woodside 40 Woodside Road Selly Park Birmingham B29 7QS     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Kulwant Ghuman     Date: 0 8 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 32 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Woodside 40 Woodside Road Selly Park Birmingham B29 7QS 01214713700 01214713411 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Birmingham City Council (S) care home 22 Number of places (if applicable): Under 65 Over 65 22 dementia Additional conditions: 0 Additionally to the above minimum staffing levels, there are also 2 waking night care staff and a senior on sleeping-in duty. Care/shift manager hours and ancillary staff should be provided in addition to care staff That minimum staffing levels are maintained at 4 care assistants plus a senior member of staff throughout a 14.5 hour waking day That the home be registered to provide care for up to 21 service users with dementia who are over the age of 65 years and one named service user with dementia under the age of 65 years. Date of last inspection Brief description of the care home Woodside is a care home providing personal care and accommodation for 22 older people with dementia. The City of Birmingham, Social Care and Health department own Woodside. Woodside is a compact single-storey building, set well back on the corner of Woodside Road and Warwoods Lane, and ten minutes walk from Pershore Road, with its shops and frequent buses to and from the city centre. All bedroom accommodation and facilities are found on the ground floor, which is split up into two units known as Laurel and Willow. The accommodation and facilities are of good quality Care Homes for Older People Page 4 of 32 Brief description of the care home with bathrooms that are well adapted, corridors that are wide and bedrooms that are of a good size. There is off road parking to the front of the building, and an enclosed garden to the rear. Some bedrooms have en-suite facilities. The home offers both long and short-term care including a respite service for carers. Fees at the home are dependant on the financial assessments carried out by the placing social workers. Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: One inspector carried out this inspection over one day in January 2008. The last key inspection was carried out on 19th February 2008. Prior to the inspection the manager completed the Annual Quality Assurance Assessment (AQAA) and returned it to us providing us with some additional information about the home. We sent seven questionnaires to the home to give out to the relatives of the people living in the home and seven to people who worked in the home. We received one questionnaire completed by a member of staff and four completed by relatives. People told us that they were generally happy with the home. The home did not know that we were going to visit them on that day. During the visit Care Homes for Older People Page 6 of 32 we spoke to the acting manager, an assistant manager, a senior care and briefly to one member of staff. We also spoke to three visitors at the home and two of the people living there. We looked at three files belonging to the people living there, one staff file and other documents to look at the way the home was being managed. We also had a look around the home and had lunch with the people living there. We had received one complaint regarding the home and this had been returned to the provider to look into. The issue had not been fully concluded at the time of this inspection. There had been no issues of adult protection at the home. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. Care Homes for Older People Page 8 of 32 The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 32 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes admission process ensured that sufficient information was received by them before people were admitted to the home. This enabled the home to make a decision as to whether the individual would be suited to the home. People moving into the home were provided with the opportunity to look around and were given written information about what they could expect from the home. Evidence: The statement of purpose, updated in July 2008, states that the home is registered to care for one person under 65 years of age. This was a condition applicable to one named person whilst they were living in the home. In addition the service user statement refers to the current acting manager as the Registered Care Manager. At the time of this inspection although the individual had been managing the home on a day to day basis since June 2008 no application for registration as a care manager had been received by us. This could be seen as misleading. Care Homes for Older People Page 11 of 32 Evidence: The statement of purpose indicated that the fees in the home were assessed by the placing social worker. A copy of the service user guide was available in the bedrooms. There was an easy read format available of the services provided in the home. There were residential agreements on the files looked at that told the people living in the home what they could expect from the home and the room that they would be occupying. In the majority of cases these were signed on behalf of the people living in the home by their representatives. We were told that the home has two interim care beds. This means that people who were ready to be discharged from hospital but who would benefit from stay in the home for a maximum of 6 weeks could be admitted. There were also two beds allocated to provide short stays in the home. This enabled carers to take a short break from their caring roles. The files of three people were looked at to assess the admission process. Social workers provided information about the needs of the individuals and the home carried out their own assessments. One one occasion this information had not been received before the individual moved into the home as it was an emergency however for the others it had. It was not always appropriate for people coming from hospital to come for a visit to the home before admission but wherever possible this was encouraged. The relative of one person who had moved into the home told us that came to have a look around the home before they decided that the home was the right place. The home collected some basic background information that was quite useful however the forms were not dated or signed and did not indicate who was providing the information. Care Homes for Older People Page 12 of 32 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Individual Service Statements did not have sufficient personalised information to enable staff to know how to assist the people living in the home. Not all risk assessments were in place and up to date. The health needs of people living in the home were adequately met. The management of medicines in the home was generally good but some aspects needed to be improved. Evidence: The files of three people who had received a service at the home were looked at to determine whether the home had been able to meet their needs. One of the people whose care was being looked at was not living at the home at the time of the inspection as there had been some difficulties with their behaviour and they had gone elsewhere for a full assessment. The Individual Service Statement (ISS) that should tell the staff exactly what the needs of the individual were and how they were to meet them was not found at the Care Homes for Older People Page 13 of 32 Evidence: time of this inspection. The information received from the placing social worker included some good detail about behavioural issues that had been experienced where the person had lived before, however, this information was not received until a few days after the person had been admitted to the home on an emergency basis. Another person who used to attend the home for respite was admitted to the home on a long term basis. There was an ISS in place however, the detail in it was very brief and the information provided by a relative in respect of their needs was not included in the ISS. Since the individual had been attending the home on a respite basis the home would have gathered information about their needs that could have been used in formulating the ISS. There were no risk assessments in place for this individual. The third individual had been living at the home for several months. The ISS had some good information in it for example, that the individual did not like anyone to bath them but for health and safety reasons the staff would stay in the bathroom but not assist them. In other areas the information was too brief, for example, staff were to assist with dressing but it did not state how or what assistance was needed. There were no details on the ISS on how the individuals medical needs were to be managed, for example, was there any blood sugar monitoring for diabetes. The medication for this individual was being given covertly however this was not noted in the ISS or which medicines needed to be given covertly. There were risk assessments in place however, these were not always dated and therefore it could not be determined whether they had been updated or when they needed to be updated. The behaviour management plan for one of the individuals whose care was being tracked was not in a file that was accessible to the staff on the units. Risk assessments needed to be accessible to the care staff and some risk assessments such as pressure sore assessments were not seen on any of the files sampled. At the time of the last inspection there were pressure sore assessments in place but the risk rating and management plans were not. Where risk assessments and ISSs were in place they were not being updated when changes were identified. Staff needed to be mindful that the recordings they made showed what was happening Care Homes for Older People Page 14 of 32 Evidence: on a daily basis. For example, one person was prescribed medication to manage their night time behaviour however, the daily records did not indicate what behaviours had led to the medicines being prescribed. Also on occasions the records made comments such as very unsettled with no explanation about how this was shown or what had let up to it. There was evidence that there was good contact with medical professionals including GPs, chiropodists, dentists and psychiatrists. There were two dentists and chiropodists providing a service to the people living in the home improving choice for them. The GP for the home held weekly surgeries there and made additional visits if needed. The home continued to use a monthly monitored dosage system for the management of medicines. The pharmacist carried out regular audits of medication in the home. The management of medicines was generally good with boxed medicines being counted on a regular basis. The audit we carried out on the day of the inspection showed that for one person living in the home one medicine that should have been returned to the pharmacist was still in the medicines trolley. The cream charts for that individual could not be found so that it could not be assessed whether the creams were being applied as required. For another person it was noted that a tablet was to be given on a weekly basis and the Medicines Administration Record (MAR) stated what date it should have been started on. However the medicine was not given on that date although it had been given during the following two weeks. This error had not been picked up any audits. There was one individual who was receiving there medication crushed up and given covertly. There was a record in the file that indicated that this had started in September however, the letter confirming this from the consultant was dated December and named only one medicine. There was no letter on the file from the GP confirming instructions had been given in September however, the GP faxed a note to the home on the day of the inspection saying the medicines could be administered crushed and mixed with a`soft drink dated September. It did not say which medicines needed to be given in this way. It was important that the home only administered medicines covertly where there was a risk to the individual and forwhich they had been given specific authority. This decision must be reviewed on a regular basis. The controlled medicines register was checked and found to be correct. Care Homes for Older People Page 15 of 32 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The level of social stimulation for the people living in the home could be improved. There was good communication between the home and the representatives of the people living in there and people can visit at all times of the day. The food provided is plentiful and of good quality. Evidence: The ISSs recorded the hobbies and preferred activities for the people living in the home, for example, one person liked to watch cowboy films and go out for walks however they did not state how these needs were going to be met. We were told that the activities held in the home included two students visiting the home on a weekly basis to chat with the people living there. There was a weekly visit from the hairdresser and the GP and nail care was usually done on the same day as the hairdressers visits. One of the visitors spoken to during the day told us that there had been an activity that morning and that there were activities sometimes when they visited. Care Homes for Older People Page 16 of 32 Evidence: Questionnaires completed by relatives told us that the home keeps people safe and well fed, also warm and clean; I am very satisfied with the care and am always made welcome when I visit; The home are good at advising me if any problem has arisen, of which I should be aware. One of the completed surveys returned to us said I know it would be difficult but it would be so nice if they could be taken out. Another said Physically I believe a good job is done but there seems to be little mental stimulus. Another visitor told us that there had been a very nice Christmas celebration at the home and the home had been nicely decorated for Christmas. We were told by the manager that there was not a set activities programme however it was expected that there were at least two activities a day. The records did not show that these were always taking place. The records for the comforts fund showed that there had been occasional entertainers coming into the home. We were told that there had been two meetings with the people who lived in the home since last June. One was to introduce the new manager and the second was to discuss the Christmas arrangements. We were able to join the people living in the home for lunch. The meal was well presented and tasted good. It was observed that those requiring assistance to eat their meal were given this in an appropriate way by staff sitting with them at the tables. There were some good interactions observed between the staff and the people living in the home. There was a board in the dining room that showed what the meals for the day were. No choice was identified on the board and when queried we were informed that if an individual did not want what was on the menu something else would be provided. The people living in the home were asked the previous day what they wanted. We were told that the kitchen staff kept a record of what individuals had had to eat on a daily basis however, for individuals where food intake was a concern more detailed records were kept. We saw these records. At the time of the last inspection an issue had arisen about the small portions of food and the small plates used for the meals. We were told that the small plates had been taken out of use. There were no indications that the portion sizes were too small on Care Homes for Older People Page 17 of 32 Evidence: this inspection. People were offered second portions and some people took up this option. The mealtime was a pleasant experience with people being given time to eat at their own pace and desserts being served as the first course was finished by individuals. This meant that people did not have to wait for everyone to finish the first course before the dessert was served. It was noted that there were no serviettes on the table we sat at and two people were seen to wipe their mouths on the corner of the table cloth. The meals came plated up from the kitchen. Individuals were not asked if they wanted gravy on their meals or not. There were no condiments on the table. The people eating in the dining room were given a choice of drink. Although it may not be practical to leave things such as sauces, drinks or condiments on the tables at all times the manager needed to consider ways in which people could be given choices about sauces and condiments as well as the plating up of meals at the tables. One of the visitors to the home told us that they occasionally had something to eat with the people living in the home and had found the food to be very good. Fresh fruits were available in the small kitchens. Care Homes for Older People Page 18 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home are protected and any concerns raised are taken seriously and addressed wherever possible. Evidence: Three complaints had been recorded in the home. One regarding issues of care for one person, one about odour in the home and one about the care given to someone admitted to hospital. The latter complaint was also referred to us as the complainant did not feel it was being dealt with appropriately. This complaint had not been concluded at the time of this inspection. The other complaints had been appropriately addressed and records were available in respect of these. There had been one incident in the home between two of the people living there and this had been managed appropriately. One of the completed surveys sent to us said ...concerns were talked about and issues raised on both sides, since when things have improved and concerns dealt with with some success. Care Homes for Older People Page 19 of 32 Care Homes for Older People Page 20 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The premises were generally well maintained and met the needs of the people living in the home. Evidence: During the inspection a tour of the communal areas was undertaken. The lounges were found to be comfortable, clean and warm. The dining area was suitable and spacious. The corridors were wide and had support rails in place. The lighting throughout the home was suitable. The bathrooms had had an additional emergency call pull installed. The bathrooms and showers had been adapted to enable the people living in the home to be assisted when bathing. The bathrooms had had star locks fitted. We were told that this was due to health and safety reasons. The bathroom doors had locks on them that could be opened from the outside in the event of an emergency. If the doors needed to be kept locked then these locks could be used and if someone was accidentally locked in they could unlock the door whereas they would not be able to open a star lock without a key. Care Homes for Older People Page 21 of 32 Evidence: One of the shower rooms had had a leak and the ceiling was in need of redecoration. There were also wall tiles that had cracked that needed to be replaced. A couple of bedrooms were looked at and found to be suited to the needs of the people living in the home. There was a variety of bedroom sizes. Some bedrooms had their own en suite facilities available. For bedrooms without these facilities there were communal toilets and bathing facilities available. The small unit kitchen had a fridge in it for storing small amounts of food. It was important to monitor the temperature of the fridge to ensure food was being stored at the appropriate temperatures. During the tour of the building the emergency call system was triggered in one of the bedrooms. A staff member attended to the call quickly however, the call was cancelled from the corridor. The call system must only be cancelled from where the call was triggered to ensure that individuals are not left without assistance. The manager must ensure that the system is adapted so that this is not possible. Care Homes for Older People Page 22 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels were appropriate for the number of people living in the home. Recruitment procedures were robust. The level of training provided to staff was not assessed as the training matrix was not available. Evidence: The staffing rotas showed that generally there were four care staff and a senior member of staff on duty during the day. At night there were two waking night staff and a sleeping in member of staff. At the time of this inspection there were 18 people living in the home and the staffing levels enabled the needs of the people living there to be met. The manager needed to ensure that staffing levels were appropriate when the home was fully occupied. One of the surveys returned to us did not feel that there were sufficient staff on duty to meet the individual needs of the people living there. The home was using some casual and agency staff to fill gaps where there was a shortfall. These staff would continue to be used when staff left to go the new care centres being opened by the City Council. The file of one new member of staff was looked at and it showed that all the Care Homes for Older People Page 23 of 32 Evidence: appropriate checks had been undertaken before the individual started their employment. The individual had had a brief introduction into the home but the file did not evidence that a skills for care induction programme had been started or that any records were being maintained on the probationary period for the individual. It was important that the individual was provided with support and information particularly as the individual had not previously worked in the care field. The manager needed to ensure that the individual was working with someone else until such time that she was sure that the individual had the skills and knowledge to work on their own. We were told that some staff were undertaking distance learning in dementia care. Those staff who were not were being nominated for departmental training in dementia awareness. We were told that staff had also been nominated for other training. The training matrix was not available at the time of the inspection and it was requested that this was forwarded to us as soon as possible following the inspection. The home was requested to forward a copy of the training matrix to us as soon as possible after the inspection. Care Homes for Older People Page 24 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home benefited from a well run home. The people living in the home, staff and visitors were safeguarded from harm. Evidence: The acting manager had been managing the home since June 2008. No application for registration had been received by us. It was important that there was an accountable person who was responsible for the day to day management of the home to be in place. The fire training record indicated that fire training was last undertaken on 11.4.07 and this needs to be repeated. The manager was receiving support from a representative of the Local Authority who visited the home on a regular basis. Unfortunately the reports of these visits were not available in the home at the time of the inspection. The last report was dated July Care Homes for Older People Page 25 of 32 Evidence: 2008. We were told that the audits for the quality assurance system had not been happening but they would be starting again. We looked at the records held for any purchases made on behalf of the people living in the home. The records were satisfactory with numbered receipts available and two signatures for expenditures. The AQAA gave us information about the servicing and maintenance of equipment in the home. This told us that the hoists and gas equipment needed to be serviced. We checked that this had been undertaken and this was confirmed. We looked at the fire records and found that the weekly fire alarm had last been tested on 30.12.08 and the monthly emergency lighting on 2.12.08. This meant that both of these tests were overdue by a few days. The manager needed to ensure that these tests were carried out at the required intervals even if the maintenance operative was not available. Care Homes for Older People Page 26 of 32 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 13 Management plans for all identified risks must be in place. This will ensure that all risks are appropriately managed. 28/02/2009 2 7 15 Individual Service Statements must show how each area of need will be met. This will enable care staff to provide person centred care. 28/02/2009 3 8 13 A pressure ulcer risk 28/02/2009 assessment must be in place with the appropriate management plan. This will ensure that the risks for people living in the home are appropriately managege. 4 9 13 The medication system must 28/02/2009 clearly show that the people living in the home receive their medication as prescribed. Care Homes for Older People Page 28 of 32 This will ensure that the people living in the home receive the medication they are prescribed according to the prescribers instruction. 5 9 13 Where medication is to be given covertly clear instructions of which medicines and how they are to be given must be recorded. This will ensure that people unable to make decisions for themselves are safeguarded. 6 30 18 The manager must ensure 28/02/2009 that new staff have the skills and knowledge to be able to provide appropriate care before they are left to do so on their own. This will enable the people receiving a service to be assured that they are cared for by suitably trained and knowledgeable carers. 7 38 23 Testing of Fire equipment must be carried out at the appropriate intervals. This will ensure that the equipment is in working order. 8 38 23 Staff must receive fire training every 6 months. This will ensure that they will know what to do in the event of a fire. 31/03/2009 19/02/2009 28/02/2009 Care Homes for Older People Page 29 of 32 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The statement of purpose and service user guide need to be updated to ensure the information given to people is accurate. All forms should be dated and signed. This will ensure that individuals take responsibility for the information accumulated. Daily recordings need to show what has happened during the day and night so that it is clear why actions are being taken. They need to clearly describe any behaviours and what has been happening before this. 2 4 3 8 4 5 8 9 Risk assessments and ISSs needto be dated so that they can be regularly reviewed. Any unused medicines at the end of the medication cycle should be returned to the pharmacist. This will ensure that there are no medicines that are unaccounted for in the home. The ISS should show what actions are to be taken to meet the social needs of the people living in the home on an individual basis. A record should be kept of all activities taking place and the individuals taking part. The manager needed to look into ways in which the promotion of choices at mealtimes could be encouraged. All areas of the home must be maintained adequately decorated and repaired. This will ensure that all areas of the home are comfortable and safe. The star locks on the bathroom doors should be disabled. This will prevent people being locked in accidentally. The emergency call system must be adapted to ensure that it cannot be cancelled before the point of call has been visited by staff. The temperatures of all fridges should be monitored to ensure that they are within required limits. This will ensure that food will be stored safely. The manager must ensure that there are sufficient staff on duty to meet the needs of the people living in the home. Page 30 of 32 6 12 7 8 9 12 15 21 10 11 21 22 12 26 13 27 Care Homes for Older People 14 15 16 30 31 33 The manager must forward a copy of the updated training matrix to the Commission as soon as possible. An application for the registration of the manager should be made. Audits to inform the quality assurance system should be started up again. Care Homes for Older People Page 31 of 32 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 32 of 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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