Inspection on 20/09/06 for Woody Point

This inspection was carried out on 20th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woody Point 05/09/07

Woody Point 04/10/05

Woody Point 25/05/05

Woody Point 16/12/04

Woody Point 11/08/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Woody Point Station Road Brampton Beccles Suffolk NR34 8EF Lead Inspector Claire Hutton Unannounced Inspection 20th September 2006 12:30 Woody Point DS0000059654.V312837.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 Woody Point DS0000059654.V312837.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. Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woody Point Address Station Road Brampton Beccles Suffolk NR34 8EF 01502 575735 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) ambercare@brampton.homepcinternet.co.uk Amber Care (East Anglia) Ltd Mrs Karen Ann Palmer Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 4th October 2005 Brief Description of the Service: Woody Point is a registered care home for five adults with learning disabilities. It changed its category of registration early in 2004, in response to the fact that each of the service user’s living there had reached 18 years of age. The Certificate of Registration for the home now reflects the fact that the home may only accommodate five young adults in the age range 18 - 25 years. Woody Point is a large extended bungalow, set back from the road that runs through the hamlet called Brampton Station. The nearest town to the home is Halesworth. The home is privately owned by Amber Care (East Anglia) Limited. Each service user has their own bedroom. There are three communal areas for social recreation including a lounge / dining room, a snoozelum, and an activity room with a range of musical equipment, arts and crafts materials, videos and books. A conservatory has been added to the side of the house, and this is used as the laundry. The home does not have designated sleeping-in facilities for staff, as the home employs waking night staff, to cover each night. Fees for this home range from £1.000 to £2.500 per week. Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that focused upon the core standards relating to Adults (18 – 65). It took place on a weekday and lasted for five and a half hours. The process included a tour of the home, meeting and chatting with the three current residents and staff on duty, observations of staff and service user interaction, and the examination of a number of documents including residents care plans, medication records, the staff rota, recruitment, training records and records relating to health and safety. The report has been written using accumulated evidence gathered before and during the inspection. Three completed comment cards were received back from residents. These had been completed by the designated keyworkers due to the level of disability of the residents concerned. All comments were positive in their responses. What the service does well: What has improved since the last inspection? What they could do better: At the time of the inspection the registered manager was on long term absence from the home and planned to resign. The deputy manager was acting up in the position as manager. Since the inspection the Commission have been Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 6 notified that the registered manager has resigned. Therefore the Commission awaits the application for a manager of the home wishing to become registered. There was some information available in pictorial format for the residents. However this had not been updated and there was not a service users guide available. This would be of use not only to the current residents, but also to give prospective residents as the home currently has two vacancies. In relation to care plans there does need to be more consistent review in line with the standards. Medication was generally well managed but old medication must be returned and where medication is in stock from one month to the next the stock total should be recorded on the medication administration sheet. Whilst examining the medication an error was noted. The acting manager agreed to investigate this and take the necessary action. Complaints are taken seriously, but this needs to be further developed and a log of all complaints must be kept with the outcome and action taken recorded. Environmentally the home is under a lot of wear and tear from the resident group, but is quite well managed, but the radiators had previously had foam on the top, this has been removed and these now need to be made good. The washing machine has been replaced with a domestic machine, but this does not conform to infection control measures required for dealing with foul linen, therefore an appropriate solution for cleansing linen needs to be found. Staff recruitment records were not available for inspection and some staff need update to date training in first aid and food hygiene. The deputy manager at the home was unable to provide evidence of selfmonitoring, reviews and development plans within the home. Therefore this is an area that needs to be developed. 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. Woody Point DS0000059654.V312837.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 Woody Point DS0000059654.V312837.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5. Quality in this outcome area is good. Prospective residents can expect to have their needs and aspirations assessed and be able to ‘test drive’ the home. Their representatives will be provided with current information, but information such as a service users guide, terms and conditions with contracts may not be available. EVIDENCE: The home has a Statement of Purpose available for people to examine at the home and this contains useful information. This would be helpful to any person considering placing a resident at the home or wishing to find out more about Woody Point. There was other information available in pictorial form for residents, but the service users guide was not available for inspection. It would be helpful to the resident group currently at the home and any prospective resident to have information such as that specified by the service users guide. In discussions about contracts, the acting manager was unable to find any information at the home about these and believed these to be held at the head office and not at the home. The acting manager was able to discuss around plans that would be in place for prospective residents and the need to obtain assessments and have a trial stay at the home. This was said would happen over a period of time, as the compatibility of the current resident group and a new resident would have to Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 9 be determined. No new resident had moved into the home for sometime, but there was evidence of assessments for the current resident group. Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 Quality in this outcome area is good. Residents, and their representatives can be confident that the plans of care maintained at the home generally reflect and address the individual and changing needs and aspirations of the person concerned. Not all plans may be consistently reviewed. Individual support and choices are positively promoted from staff. EVIDENCE: There was a care plan in place for all residents and these were in the process of being developed further. The proposal is to make them more accessible as they will be based around the primary care needs of the individual e.g. their behaviour that challenges. One of the care plans that was examined had not been reviewed since November 2005, therefore would benefit from this new approach. The care plans were of sufficient detail to give staff adequate information about the levels of support individuals needed. The care plans had been developed from the assessments made on individuals. This included risk assessments that were both generic and had individual elements that promoted independence and freedom where possible. Examples of risk assessments in place included the home environment such as use of the kitchen and the fire extinguishers sited around the home. Risk assessments Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 11 for outside the home included out walking, traffic, ponds, rivers and swimming. The daily statements made by staff were of good quality and stated what support had been given to enable the residents to maintain as much independence as was possible. Staff were observed to interact with residents in a respectful way encouraging them to participate in tasks around their own home. This included one individual preparing a snack. Information about residents is handled in confidence and in a sensitive manner. The home has a policy on access to service user information and a confidentiality policy. Both of which are accessible to staff. Staff recorded in the daily statement activities undertaken, personal care given, food eaten and sleep patterns. The detail was informative. Staff spoken to demonstrated a good knowledge of assessments and of individual care needs. Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. Residents, and their representatives can be confident that the home enables residents to maintain appropriate lifestyle with individual opportunities and support. Decisions around personal, family and sexual relationships are respected. EVIDENCE: Evidence from care plans, daily statements and from talking to staff confirmed that the opportunities to socialise and participate within the local community were many and quite individual. Each resident had an individual plan of day care. This was developed at the Amber care day services at Crown House. Opportunities included gym, swimming, art and craft, woodwork and a meal preparation day, as well as community participation. The week following this inspection the day service was planned to close, but different opportunities were planned with day centre staff – such as a trip to the beach and a walk in the woods. Individual holidays have been planned and taken this year to places such as Skegness, Bognor and Thorpe park. Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 13 Care plans and staff demonstrated that residents were able to see family and friends of their own choosing. One resident had recently been supported to visit family members some distance away from the home. The home has a policy on sexuality and relationships. The menus that have been created are with the involvement of the residents. This was seen as individual preferences were catered for. Food shopping is delivered regularly from local retailers. Residents were seen to be participating in the meal preparation and making choices around food that they liked. The menu was displayed in the kitchen and was traditional type home cooking with a roast on a Sunday, pasta dishes and curries. On a Saturday there was an individual choice day and individual residents made their own meal. The dining room was part of the kitchen area and had smaller tables to accommodate individuals with support if needed. Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. Residents, and their representatives can be confident that the home offers appropriate personal and health care support. Trained staff acceptably manage medication, but current practice could be further developed. EVIDENCE: Care plans set out the support the residents required. All three residents questionnaires were positive about the support offered. Observations made whilst at the home show that each resident has a one to one support person who is designated and does offer individual support with all tasks. Care plans recorded all health care and professional visits made. Entries were seen for chiropody, dentist and GP. Staff were aware of specialist referrals to clinical psychologists and these were recorded. Medication was on the whole well managed with the home. All staff were adequately trained in the system adopted by the home. Security of medication was adequate. The home has a monitored dosage system in place provided by a local chemist. This same chemist had conducted an audit for the home and made three recommendations that the home had actioned. Medication administration records were seen to have been consistently completed, with the initials of the person administering the medicine recorded on each Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 15 occasion. There is a clear and concise medication administration procedure for staff to follow. However a detailed medication policy and procedure for other aspects of medication was not available for inspection. Medication for one resident was audited. This did not tally exactly as one infrequently used medication was not carried forward from previous months. Therefore this should be noted each month at the start of a medication administration record for routine auditing to take place. In addition medication held in the name of previous residents should be returned. Whilst examining the medication an error of administration was found. Medication had been signed for but was still in the blister pack. The deputy manager agreed to investigate this matter and take action to ensure it did not happen again. A list of sample signatures and initials of staff would easily identify staff that administered medication. The deputy manager agreed to action this recommendation. Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. Residents, and their representatives can be confident that the home has appropriate procedures in place to deal with complaints, protect residents from abuse, neglect and self-harm. However records must further be developed to evidence this practice. EVIDENCE: The home has a complaints procedure in place and this is displayed at the home and is part of the Statement of Purpose. The Commission has not received any complaints in the last year, but the home had one. This was taken seriously and the deputy manager explained that it had been dealt with. However, the home is required to make a record of every complaint and the action taken by the registered person in respect of any such complaint. This was not available for inspection. In relation to protection of residents both the deputy manager and staff have received appropriate training. The home has the up to date Suffolk Protection of Vulnerable Adults (POVA) inter agency policy, procedures and guidelines for staff to access. Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30 Quality in this outcome area is good. Residents, and their representatives can be confident that the home is comfortable, well maintained and meets the needs of the existing resident group. EVIDENCE: The home is subject to a lot of wear and tear but from a tour of the home it was evident that it is well maintained. All communal areas are comfortable and clean and have personal touches that make it homely, but safe for residents. The radiators previously had foam covering to the top as a protection measure for a previous resident. This foam had been removed, but has left a scruffy appearance to the radiators. Each bedroom seen was a reflection of the person who resided there. Feedback from residents is that they are happy with their accommodation. None of the bedrooms had en-suite facilities, but are not required to have this as the home was registered before August 2002. They are required to have a wash hand basin as a minimum standard. This was discussed with the deputy manager. Wash hand basins were removed from bedrooms, as the residents were risk assessed and these facilities were found to be unsuitable. However in light of the two vacancies this facility should be reviewed for any new service user. Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 18 The home has three bathrooms and two separate toilets. All of the toilets require liquid soap for residents, visitors and staff to wash their hands adequately after using the facilities, as this will minimise spread of infections. The laundry room is in the conservatory extension and is very clean light and well ventilated. The home previously had an industrial washing machine to deal with foul laundry. However when this had recently broken it had been replaced with a domestic washing machine, but this does not conform to infection control measures required for dealing with foul linen, therefore an appropriate solution for cleansing linen needs to be found. Residents have access to a wide range of communal areas including a spacious lounge, an activities room with music equipment, CD Player and games and a snoozelum. residents have access to the kitchen with staff support and there is also a small separate dining room. Externally there is a large and well-maintained garden area with decking. Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34 and 35 Quality in this outcome area is adequate. Residents, and their representatives can be confident that the home employs suitable numbers of staff that are adequately trained to meet the needs of the residents. A judgement about staff recruitment is unable to be made. EVIDENCE: The staffing roster for the home was examined. This runs on a four week rotation, however the deputy manager said this was due to change to give more consistent time off for staff, but still meet the needs of the residents. The roster showed that residents were out at day services during the day time, but in the evenings staffing was three staff on duty. At night there was two awake staff who stayed to see the residents off to day services. A third member of staff also joined them at 7am. At a weekend staffing levels were at three staff during the day. The home employs nine staff in total. Two new staff had recently been recruited and are doing their skills for care induction. Five staff were said to have done or completing NVQ level 3 in care. Evidence of an NVQ assessor was seen in the visitors book. Staff had received fire training in October. Planning for staff training and updates was in hand and some staff required updates in food hygiene and first aid. The deputy manager confirmed that three staff had yet to undertake their ‘unisafe’ training. This is training that teaches staff to manage behaviour that challenges. Two staff spoken with felt Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 20 they were adequately trained to do their job. Staff spoken with expressed a feeling of discontent. This was explained that due to being overstaffed because of resident vacancies then staff had been requested to work at other establishments where they were needed. Staff had not welcomed this change in their working location. Records required to be kept at the home include staff recruitment records. These were said to be held at head office. Therefore a judgement as to the adequacy of these cannot be made. Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. Quality in this outcome area is adequate. Residents, and their representatives can be confident that the home is appropriately managed in regard to health and safety. However the Commission awaits an application for a registered manager and areas such as self monitoring and records needs to be further developed. EVIDENCE: As mentioned in the summary report at the time of the inspection the registered manager was on long term absence from the home and planned to resign. The deputy manager was acting up in the position as manager. Since the inspection the Commission have been notified that the registered manager has resigned. Therefore the Commission awaits the application for a manager of the home wishing to become registered. The deputy manager at the home was unable to provide evidence of selfmonitoring, reviews and development plans within the home. Therefore this is an area that needs to be developed. Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 22 In relation to policies and procedures and records required to be kept at the home there is a comprehensive folder of policies and procedures available for staff to read. However two key pieces of information required is the development of a medication policy and records relating to staff recruitment must be available for inspection at the home. In relation to health and safety in the home staff were appropriately trained in health and safety. All records relating to fire were in place and up to date. Hot water temperatures for bathing were recorded. Temperatures were taken on the day and were well within acceptable safety limits. Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 23 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 2 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 3 32 3 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 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 2 X 2 X 1 X 2 3 X Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 YA1 Regulation 5 Requirement Residents must be provided with an up to date service users guide. Residents must be provided with the terms and conditions in respect of the provision of accommodation and personal care and a contract for the provision of services and facilities. If these arrangements are made through the local authority a copy of the agreement must be supplied to the resident and be available for inspection. The plan of care must be reviewed with the service user at least every six months and reflect changing needs and agreed changes are recorded and actioned. A policy and procedure for dealing with medication at the home must be developed. Medication no longer required due to residents leaving the home must be returned to the pharmacy. The medication error found at DS0000059654.V312837.R01.S.doc Timescale for action 06/11/06 2. YA5 5 06/11/06 3. YA6 15 (20(b) 06/11/06 4. 5. YA20 YA20 13 (2) 13 (2) 06/11/06 06/11/06 6. YA20 13 (2) 06/11/06 Page 25 Woody Point Version 5.2 7. YA20 13 (2) 8. YA22 17 (2) schedule 4 23 (2)(b) 13 (3) 9. 10 YA24 YA30 inspection must be investigated and action taken to prevent a reoccurrence. The medication administration record must state how much medication is in stock. Therefore any carried forward medication must be recorded. A record of all complaints made must be kept at the home and this must include action taken by the registered person in respect of any such complaint. The radiators around the home must be made good. Toilets must have liquid soap provided to allow people to clean their hands to prevent spread of infection. The domestic washing machine does not conform to infection control measures required for dealing with foul linen, therefore an appropriate solution for cleansing linen needs to be found. The staff training and development programme must ensure that staff fulfil the aims of the home and meet the changing needs of the residents, therefore staff require updates in basic food hygiene, first aid and attend ‘unisafe training’. Effective quality assurance and quality monitoring systems, based on seeking the views of residents, must be in place to measure success in achieving the aims, objectives and statement of purpose of the home. Records required by regulation for the protection of service users and for the effective and efficient running of the business must be maintained, up to date DS0000059654.V312837.R01.S.doc 06/11/06 06/11/06 06/11/06 06/11/06 11. YA35 18 (1) (c) 06/11/06 12. YA39 24 06/11/06 13. YA41 17 06/11/06 Woody Point Version 5.2 Page 26 and accurate. Therefore a policy on medication and staff recruitment records must be available for inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA20 YA26 Good Practice Recommendations A list of sample signatures and initials of staff would easily identify staff that administered medication. The registered person should provide each resident with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Therefore the lack of wash hand basin should be reviewed in the respect of each new resident to the home. Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Woody Point DS0000059654.V312837.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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