Inspection on 04/12/06 for 15 Woodville Road

This inspection was carried out on 4th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

15 Woodville Road 28/02/06

15 Woodville Road 20/06/05

15 Woodville Road 04/02/05

15 Woodville Road 02/09/04

15 Woodville Road 05/03/04

15 Woodville Road 21/01/04

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 Woodville Road, 15 Harborne Birmingham West Midlands B17 9AS Lead Inspector Brenda O’Neill Unannounced Inspection 4th December 2006 09:20 Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodville Road, 15 Address Harborne Birmingham West Midlands B17 9AS 0121 428 2455 0121 428 4660 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) New Outlook Housing Vacant. Care Home 5 Category(ies) of Learning disability (5), Sensory impairment (5) registration, with number of places Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 28th February 2006 Brief Description of the Service: Woodville Road is a large traditional house. There is accommodation for five younger adults with a visual impairment and an associated learning disability. The home is staffed 24 hours a day including waking night and a sleeping in member of staff. Residents would be admitted to the home following a full assessment that would determine the level of support they require. The full range of medical services, leisure and social activities are provided for the residents. Residents are encouraged and supported to maintain links with their families and the local community. The care needs of the residents are monitored and reviewed and action is taken to address any concerns. The home has a ramped access and has recently had a shaft lift installed to enable easy access to the first floor. All bedrooms are of single occupancy. One bedroom is on the ground floor and four are on the first floor. There is a floor level shower and a toilet located on the ground floor and a bathroom with an assisted bath and toilet on the first floor. There is a lounge/diner, large kitchen, small laundry, office space and staff facilities also located on the ground floor. The home is in Harborne, a residential area of Birmingham. It is in walking distance of shops, pubs, parks, places of worship and public transport. The fees at the home start from £982.00 per week and are dependent on the level of care required by individual residents. Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this key unannounced inspection over one day in December 2006. During the course of the inspection a tour of the home was carried out, two resident and three staff files were sampled as well as other care and health and safety documentation. The inspector spoke with the acting manager and one member of staff, met all the residents and spoke with three of them. Prior to the inspection one completed comment card was received from a relative of one of the residents. All the comments on this were very positive about the service at the home. A pre inspection questionnaire was sent out to the home asking for additional information however this was not returned to the CSCI. The home had not had any complaints lodged with them since the last inspection and none had been lodged with the CSCI. What the service does well: This is a well managed home that consistently offers a good level of service to the residents that live there. Before any new residents are admitted to the home staff carry out a thorough assessment of the person’s needs to ensure the home are able to care for them. Residents had very good care plans in place that were written from the residents’ point of view but also took into account other things staff needed to know about them. Care plans were being reviewed regularly to ensure they were up to date. Residents had both risk assessments and behaviour management plans in place. These detailed how staff were to minimise any risks identified and how any behaviours were to be managed without causing the residents any harm. Residents were able to make decisions about their daily lives within the bounds of the risk assessments. Residents’ personal and health care needs were met in a way that suited them. Residents were encouraged and supported by staff to be as independent as possible. The complaints procedure in the home was available in variety of formats including Braille and audiotape to try and ensure all residents could understand it. No staff had left the home since the last inspection which was very good for the continuity of care of the residents. Staff had a good knowledge of the Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 6 residents they were caring for. The training they received ensured they were able to meet the needs the needs of the residents well. Comments received included: ‘I like the home. Staff are very nice. They go out with me when I want to.’ ‘Woodville is a home from home environment. You are always welcomed. Staff are always cheerful and friendly. Staff are excellent, care and hygiene are excellent. I don’t have any problems.’ The home provided residents with a very comfortable, homely and safe place in which to live. The health and safety of the residents and staff at the home were very well managed. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs and aspirations were assessed prior to admission to the home and were known by staff. Residents were issued with a contract that gave details of their terms and conditions of residence at the home. EVIDENCE: No new residents had been admitted to the home since the last inspection. Two residents’ files were sampled, one for a resident who had lived at the home for a considerable amount of time and one for a resident who was fairly new to the home. There was evidence on the file of the most recent admission of a comprehensive pre admission assessment being carried out by the staff at the home. The assessment had not been signed or dated and did not state where the assessment had been carried out. It was recommended that this be done to evidence that the assessment was undertaken prior to admission to the home. It was also evident that a social worker had been involved in the admission, as there was a copy of an initial care plan drawn up by them. There was also some information that had been received from the hospital at the point of discharge. Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 9 All the residents in the home were reassessed on yearly basis to establish what their needs were and what level of support they needed. Their funding was then based on the outcome of the assessment. The files sampled had comprehensive license agreements which detailed the terms and conditions of residence at the home. Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents had comprehensive care plans and risk assessments that detailed how all their needs were to be met and how any risks were to be minimised by staff. EVIDENCE: The two files sampled included comprehensive care plans. The care plans at the home were very person centred and written from the residents’ point of view but also took into account other things staff needed to know about individuals. The one file sampled had had a lot of input from the individual concerned, the other the resident was not able to contribute fully to. The daily living skills of each resident were clearly documented and stated what they were able to do for themselves and where they needed support from staff. Areas covered included, communication, socialising, personal care and managing finances. There was a section within the care plans ‘if you know nothing else about me, you must know this’ and this included such things as ‘I Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 11 don’t like being touched’. All the individuals’ likes dislikes and preferences were also included in the plans. Wherever possible the residents at the home had signed to say they agreed with their plans. The care plans were being reviewed at least twice a year. The documentation from the reviews was very comprehensive and clearly detailed in the summary of the review what the aims for next six to twelve months were. The outcomes of the reviews had not been included in the care plans and there was no separate action plan that detailed if the outcomes had been actioned or what progress or otherwise was being made. This was discussed with the acting manager who agreed that an action plan stating what the outcomes of the review were would enable staff to monitor and record any progress or otherwise. Residents did make decisions about their lives wherever possible within the bounds of their risk assessments. Details of how they wanted their care delivered, their preferred pass times, meals, rising and retiring times were all detailed on their care plans. Residents chose on a daily basis what they wanted to eat, when they got up and went to bed and how they wanted to spend their time when they were not on structured day placement. The needs, likes, dislikes and preferences of the residents who were unable to communicate verbally were clearly known by the staff. The residents had both risk assessments and behaviour management plans in place. The risk assessments were comprehensive and covered such issues as, moving and handling, managing finances, bathing or showering, hot drinks and accessing the garden. The behaviour management plans clearly detailed how staff were to manage any presenting behaviours to a satisfactory conclusion. Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were encouraged and enabled to have an independent lifestyle as far as was possible. Their rights and responsibilities were recognised by staff in their everyday lives. The catering arrangements at the home met the needs of the residents. EVIDENCE: All residents had activity plans in place that detailed how they would access the local community. Some of the residents went to a local day centre which they walked to escorted by staff. They accessed the local shops, library, post office, park and pubs. One of the residents went out every morning to get their newspaper. At the day centre the residents took part in variety of activities. On the day of the inspection the one resident who had gone to the day centre was going swimming. Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 13 The residents’ rights to privacy were detailed in their care plans giving details of when staff could enter their room, whether they wanted a key for their bedrooms and what they wanted to happen to any mail they may receive. Residents were able to spend time in their rooms without being disturbed by staff and this was observed on the day of the inspection. There were gender care agreements drawn up with the residents stating whether they minded their care being delivered by the opposite sex. One file clearly detailed that the individual took an interest in their file and would look at it but may not remember it had been seen. Family and friends were made welcome at the home. The comment card received by the inspector stated: ‘You are always welcomed and do not have to make an appointment. Can visit any time.’ The resident’s personal files evidenced good contact with families and that residents were able to go out with their families whenever they wished. One resident confirmed that they see their family every weekend and go out for a drink with them. There were no planned menus at the home. Meals were prepared based on the residents’ likes, dislikes and preferences and what they wanted on the day. Records of the food being served to the residents were being kept and they evidenced a wide variety of meals and choices. One of the residents was from a different cultural background to the other residents but had no dietary needs in relation to his culture. The acting manager stated that their relative did bring cultural foods in sometimes but the resident would not eat them. There was documented evidence that when one of the residents had been gaining weight advice was sought from a dietician and a healthy eating plan had been put in place. The resident had lost some weight and was being encouraged by staff to eat healthily on an ongoing basis but they also realised they could not monitor the food eaten when the individual was out with family. Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal and health care needs were met in ways that suited them. The medication system was well managed and safe. EVIDENCE: Residents’ preferences in relation to their personal care were detailed in their care plans. It was clear what their preferences were to gender sensitive care were. The support they needed varied considerably from those that could bath or shower independently to those who needed full support from staff. There was documented evidence that residents were receiving the support they needed to meet their personal care needs. Resident’s ongoing health care needs were detailed in their health action plans. All residents had some sensory impairments which were monitored on an ongoing basis. There was evidence of residents receiving the appropriate health care from doctors, opticians, chiropodists, dentists, dieticians and of appointments being kept with consultants. One of the residents had had new hearing aids and a lot of ongoing treatment from the dentist. The residents’ weights were being monitored on an ongoing basis. Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 15 Medication was being administered via a 28 day monitored dosage system which was very well managed. All the staff at the home had received accredited training for handling medication. Any medication that was not included in the monitored dosage packs was audited every time it was administered to ensure no errors occurred. All medication administered was signed for by two staff. All medication received into the home was acknowledged on the medication administration charts and all the medicines audited at the time of the inspection were correct. There were protocols in place for any PRN (as and when necessary medication) and these clearly detailed when the medication was to be administered. None of the residents self administered their medication and there were was no controlled medication in the home at the time of the inspection. Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints and adult protection procedures available ensure the residents are safe guarded. EVIDENCE: There was an appropriate complaints procedure at the home and this had been amended as required at the inspection in June 2005. The procedure was available in a variety of formats including Braille and audiotape. The home had not any complaints since the last inspection and none had been lodged with the CSCI. The adult protection procedures were not viewed at this inspection as they met the required standard at the last inspection. All staff employed at the home had received adult protection training. The home was managing some money on behalf of all the residents. The records for this were sampled. All the residents had bank accounts and there were copies of statements available. The manager held the larger amounts of money in the safe and residents also had what was termed as a ‘purse account’, which was money available to them on a day to day basis. There were appropriate signatures for all expenditure and receipts were available. One query did arise that some of the residents were paying for their own lunches at the day centres they attend. The inspector received a communication following the inspection to clarify this. There was a long standing arrangement in place which was that residents could have a packed Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 17 lunch to take to the day centre but if they wanted the meal provided at the centre they would pay for this. This arrangement had been agreed between individual residents and representatives of the organisation. The acting manager has since spoken to the residents affected and put a note in the relevant care files. Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided residents with a safe, homely and comfortable environment in which to live. EVIDENCE: The home had recently been extended which had added to the facilities available for the residents and staff. It was well maintained and safe. There was ample communal space at the home with a combined lounge/diner which was well furnished and nicely decorated. The dining area looked out onto a large well-maintained garden. The kitchen at the home had been refurbished. It was large, modern and well equipped. The home has one bedroom on the ground floor and four on the first floor. The bedrooms seen were nicely personalised to the occupants’ choosing and met Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 19 with their needs. It was noted that some pieces of bedroom furniture were looking well worn and were in need of replacing. Residents had the choice of either a bath or a shower. The bathroom was located on the first floor and had a parker bath installed allowing for assistance when needed. A new floor level shower had been installed on the ground floor. There were adequate numbers of toilets available for the residents. A lift had been installed in the home ensuring residents with any mobility difficulties could access the first floor. A new corridor had been created to avoid the laundry being taken through the kitchen area. The laundry was small but appropriately equipped with a washing machine with a sluice cycle and tumble drier. On the day of the inspection the home was clean and hygienic. Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well-supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There had been no staff turnover at the home since the last inspection which was very good for the continuity of care of the residents. Staff knew the needs of the residents and the relationships between staff and residents were very good. The comment card received by the inspector stated: ‘Staff are always cheerful and friendly, staff are excellent.’ The numbers of staff on duty were appropriate to the needs of the residents. The home does not use agency staff and shortfalls in staffing are covered either by the staff at the home or the organisation’s bank staff. Three staff files were sampled and all the required documentation in relation to recruitment was being held on site. All staff had individual training records which indicated that staff receive all their regulatory training and updates, for example, food hygiene and first aid. All staff had completed the Learning Disability Award Framework (LDAF). Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 21 Others training offered to staff included such topics as, epilepsy, sight loss awareness and bereavement. The inspector was informed that all but one member of staff had their NVQ level 2 in care or the equivalent. There was evidence on the staff files that supervision sessions were taking place however the frequency of these varied. The acting manager was aware that all staff should receive a minimum of six supervision sessions per year. Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed ensuring the health, safety and welfare of the residents were promoted and protected. EVIDENCE: The registered manager had left the home the week prior to the inspection. This had been put in writing to the CSCI and a new manager had been advertised for and interviews were to take place in December. At the time of this inspection the deputy manager was the acting manager. She had worked at the home for a considerable amount of time and was very knowledgeable about the needs of the residents in her care. She had a good understanding of the running of a residential home. Relationships between the acting manager, staff and residents were very good. Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 23 The home had a formal quality assurance system in place and the last assessment at Woodville road had been in October of this year. The report on the outcome of the assessment was being drawn up and this will inform the development plan for next year for the home. The acting manager stated that the system being used for quality monitoring was to be reviewed as it did not meet their needs. The health and safety of the residents and staff were very well managed. Staff had received training in safe working practices. The home was well maintained and safe. All the in house checks on the fire system were up to date and fire drills were carried out regularly. There was evidence on site of the up to date servicing of all equipment. Accident and incident recording and reporting were appropriate. Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 2 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 25 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(2)(b) Requirement A system must be put in place to evidence that the outcomes from the six monthly reviews of the care plans are actioned. Any worn bedroom furniture must be replaced. All staff must receive a minimum of six supervision sessions per year. Timescale for action 01/02/07 2. 3. YA25 YA36 16(2)(c ) 18(2) 01/03/07 01/02/07 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 YA2 Good Practice Recommendations It is strongly recommended that pre admission assessments are signed and dated. Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 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 © 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 Woodville Road, 15 DS0000016806.V321393.R01.S.doc Version 5.2 Page 27 - 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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