Inspection on 16/01/06 for Wychbury Care Services

This inspection was carried out on 16th January 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wychbury Care Services 31/07/06

Wychbury Care Services 25/07/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Wychbury Care Services 350/352 Hagley Road Pedmore Stourbridge West Midlands DY9 OQY Lead Inspector Mrs Cathy Moore Unannounced Inspection 16th January 2006 07:45 X10015.doc Version 1.40 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 Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Wychbury Care Services Address 350/352 Hagley Road Pedmore Stourbridge West Midlands DY9 OQY 01384 894093 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) Daniel Timothy Johnson Sara Naomi Bate, Adam David Johnson Ms Rachel Davenport Care Home 42 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (42), of places Physical disability over 65 years of age (12) Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25/07/05 Brief Description of the Service: Wychbury is registered to provide care to a maximum of 42 service users. Twenty seven places can be offered to service users who fall within the category of old age, three to older people who have been diagnosed as having dementia and 12 for people who are over 65 years and have a physical disability. A separate condition of registration has been approved for one service user under the age of 65 years. Wychbury is a large detached traditional building that has been extended and adapted to its present form. The home is situated in a beautiful location, with countryside views of fields, hills and livestock. The gardens surrounding the home are very attractive. The home has a large rear garden with patio areas, a good sized fish pond, a summerhouse and lawned areas. At the bottom of the garden there are fields where a number of horses graze. The home is separated into two units, the main house and the Coach House. These two buildings both have bedrooms, lounge areas, dining rooms, toilets, bathrooms and a kitchen. The main house contains the ‘home’ kitchen, laundry and offices. The home offers two lifts in the main home and a stair lift in the Coach House allowing residents’ to access all parts of the home. Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out as the second of the home’s routine inspections for this inspection year. The inspection was conducted by one inspector, on one day between 07.45 and 15.15 hours. The inspection focussed on National Minimum Standards that were not assessed during the last inspection and previous requirements made. The premises were partly assessed to include; communal areas in both sides of the home, six bedrooms, bathrooms, toilets and the garden. Two residents’ records were assessed to include assessment of need documentation, care plans, daily records and terms and condition documents. Medication systems, health and safety/ maintenance and policies and procedures were examined. Seven residents,’ three relatives and two staff were spoken to during the inspection. The manager and the deputy were involved in the whole inspection process. Not all standards were assessed during this inspection for a full overview of service delivery this report should be read together with the last inspection report dated 25 July 2005. What the service does well: The home is run as a family business. All registered persons have regular, mostly daily contact, with the home. The management continue to be keen to provide a high quality service to the people in their care. The home is situated in a residential area. First and second floor bedrooms all have impressive views over countryside. The rear garden is of a generous size, is maintained regularly and is very attractive and pleasant. It has a large patio area, a fish pond, established trees and shrubs. Horses graze in adjacent fields. The main lounge is well maintained and attractive with a new, large fish tank as a focal point. Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 6 All bedrooms with the exception of one are single occupancy. All bedrooms with the exception of one have en-suite facilities comprising of a toilet and hand wash basin. The home’s atmosphere was once again warm, welcoming and friendly. One relative commented;” We looked at loads of homes and were beginning to feel that we would never find one that was right. As soon as I walked into this home I knew it was the one. It was warm, friendly and homely”. A number of the staff have been employed at the home for some considerable time- a couple as long as 13 years ensuring consistency of care. The home should be congratulated in that 80 of the care staff have achieved N.V.Q level 2 or above in care. Positive comments were received from relatives and residents and include the following; “ The staff do well here. They have the patience of Jobe. We had a lovely show at Christmas”. “ I am quite satisfied”. “If it wasn’t for the staff I don’t think my Dad would be here. When he was unwell they were not satisfied with the doctors actions and rang 999. Communication is good”. “ The home is very nice and I have no complaints. All the ‘girls’ are very nice”. Two staff members separately commented;” I love it here, I really enjoy my work”. “ I love it here and I love the residents”. The home employs a handyperson and a full time decorator. What has improved since the last inspection? The home has improved in many areas since the last inspection. The required stone masonry work / paintwork to the front of the home has been completed. A number of windows at the front of the home, in the lounge, conservatory, and corridor off the conservatory have been fully replaced to include window frames. At least three doors have also been replaced. A fountain has been erected at the front of the home. One relative commented; “ It looked beautiful all lit up at Christmas”. At least 5 bedrooms have had work completed since the last inspection. One has had new facilities in the en-suite, two have been provided with new carpets and a number have been redecorated. New attractive, iron wrought railings have been fitted alongside the rear ramped access. One service user has been provided with decking outside of his external bedroom door giving him a private sun terrace for use in spring and summer months. Work has commenced to provide a wide path around the garden to allow full wheelchair access. Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 7 New lighting/pictures and mirrors have been provided in a number of places within the home. The home has worked hard to significantly meet a high number of past requirements made. Improvements were identified in care planning, acknowledgement letters to residents, tissue viability and nutritional assessments and documentation to evidence healthcare visits. Activity provision and menus have been expanded upon. Staff recruitment processes have also improved. 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. Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Nil No standards in this section were assessed during this inspection. EVIDENCE: No standards in this section were assessed during this inspection. Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9,10 ‘Fine tuning’ of medication systems is needed to ensure that they are effective and safe. Residents feel that they are treated with respect and their right to privacy is upheld. EVIDENCE: Good practice was observed in respect of medication systems. Only a small number of staff, mainly managers and seniors have responsibility for medications, all of whom have received accredited safe handling of medication training. The mid-day medication administration process was partially observed. Drinks and containers were made available before the process commenced. The deputy manager was observed giving residents’ tablets and discreetly ensuring that these tablets had been taken. It was positive in that medication records were not signed until the deputy was sure that the medication had been taken. The home has a medication policy. It was noted that the medication ’misadministration’ policy did not instruct staff to inform the CSCI if any situations were to arise. Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 11 It was noted that a number of medication records had been handwritten yet there was no evidence that the information written on the records had been verified as correct by 2 staff. It was noted that a number of medication records did not detail all of the required information examples being; allergies and the doctor’s name. It was identified that one resident is self administering a prescribed topical preparation however, no risk assessment to sanction this was available. Staff /resident interactions were observed and were positive. Staff giving residents choices and showing them respect. The preferred form of address for residents’ is determined at the assessment of need stage or on admission. This is recorded on the residents file and used by staff. One staff member stated “.. is his proper name but he likes to be called..”. A payphone is available for resident use. A number of residents have chosen to self finance a phone in their bedroom. All nurse/doctor assessments and treatments are carried out in the privacy of the residents’ bedrooms. The homes environment promotes privacy and dignity as all but one bedroom is of single occupancy and all but one bedroom has an en-suite facility. A number of resident choose to spend time alone in their bedrooms. Others chose to receive their visitors in their bedrooms rather than a communal area. Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Nil No standards in this section were assessed during this inspection. EVIDENCE: No standards were assessed during this inspection. Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 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 ‘Fine tuning’ of processes and policies in respect of adult protection is required to ensure that effective systems are in operation. EVIDENCE: It is positive that a number of staff have received abuse awareness training. Another course is being held in Feb 06. The home has in place a number of policies and procedures aimed to protect vulnerable adults. It was noted however, that a number of these policies require a review. For example, the missing persons policy does not inform staff that the CSCI would have to be notified. The violence and aggression policy was dated March 2004. Dudley MBC adult protection procedures-‘ Safeguard and Protect’ were available within the home. The flow chart within this file must be completed with names and telephones numbers. There was no evidence available to suggest that staff have read the abuse procedures. Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26. Generally residents’ live in a well-maintained environment. All radiators must be guarded to provide safe surroundings. Work is needed to enhance infection control processes within the home. EVIDENCE: The registered persons have had significant work carried out since the last inspection. Examples being; Stone/masonry/re-painting work to the front of the home. The replacement of a number of windows (which had to be specially made) to the front of the home, the main lounge, conservatory and corridor off. One first floor corridor and a number of bedrooms have been redecorated. A fountain has been erected at the front of the home. Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 15 New bedding and window dressings have been purchased for a number of rooms. The home is very large. Generally, it is well maintained. Work is needed in a number of areas for example toilets, bathrooms and corridors. The CSCI are however, satisfied that the registered providers have identified the needs of the home and have produced a timetable/schedule to follow. Lighting in the rooms viewed appeared adequate and are domestic in style. The water system was assessed to eliminate bacteria and was found to be negative in April 2005. Though radiator guards have been fitted to radiators during the past 2 years it was identified that the ground floor parker bath-bathroom radiator and the one in the first floor bathroom highlighted to the deputy were not guarded. Generally, the home looked clean and tidy. One relative commented,” The home is kept well”. A new domestic staff member has recently been recruited. The home has separate laundry staff. A random Infection control audit was carried out which revealed the following; The laundry is located away from any food preparation or communal area. It is equipped with two commercial washing machines capable of providing sluice cycles, one domestic washing machine and two commercial dryers. There is no sink in the actual laundry however, one is situated just outside the laundry room. The flooring in the laundry is showing signs of tear. Personal care items and ‘bar soap’ were seen in two bathrooms. Sealant and flooring in bathrooms and toilets requires attention. This has been identified by the registered persons and has been included in the refurbishment schedule. It was disappointing that ‘hand wash’ signs were not available in bathrooms and toilets. The manager was surprised at this as she has herself in the past provided these. It is positive that a high proportion of staff have received infection control training. It is also positive that adequate protective clothing – disposable gloves and aprons are available in high risk areas. Disposable bags are used for laundry purposes when dealing with soiled linen/clothing. Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30. Residents needs are met by the numbers and skill mix of staff. Residents are in safe hands at all times. Staff are trained and competent to do their jobs. EVIDENCE: The home is adequately staffed. Typical staffing levels on a daily basis are as follows; AM- 5 care staff plus one senior. PM- 5 care staff plus one senior. Night-2 care staff. The majority of the time the manager or deputy are on duty. The responsible Individual is on site during the week. Domestic, laundry and catering staff are provided every day. A discussion was held about the numbers of night staff two, which is low taking into consideration the numbers of residents and size and layout of the home. Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 17 The discussion also considered an anonymous concern received by the CSCI in respect of night staff having to do cleaning duties and vegetable preparation. The manager informed that the two night staff were adequate and if at anytime it was felt that it was not they would be reviewed. That night staff do undertake some cleaning duties and vegetable preparation but it was reinforced that the residents must always come first and if it was felt any night that the cleaning duties would have to be missed then this would be supported. It was suggested that the preparation of vegetables so long in advance may be detrimental to their nutritional value and quality. The home has achieved an impressive level of attainment in respect of N.V.Q 2 or above. To date, 16 of the 20 staff have N.V.Q. A number have level 3, the deputy is working towards level 4. Well done to all. Induction materials were available for inspection. Recent staff to commence employment have gone straight onto an N.V.Q course rather than the foundation course. A training matrix is available on the office wall. Each staff member has a training file. Generally staff have received mandatory or training required for their job role. Where they have not training has been secured via a rolling programme. Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35,38. Residents’ financial interests are safeguarded. Generally, the health and safety of residents’ is ensured although some fine tuning is needed. EVIDENCE: The home holds money in safe keeping for residents’ and relatives who require this service. On admission the resident or relative confirm in writing what their money can be used for examples being; hairdressing, chiropodist or small personal items. Money held in safe keeping is kept secure in the safe. It is contained in personal money holders. Two residents’ monies were checked against balances and were found to be correct. It is positive that an inventory was seen on each residents’ file detailing personal items that they have brought into the home with them. Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 19 Health and safety and general maintenance records/certificates were examined which revealed the following; The lifts were serviced and “ left in good working order” in Oct 2005. Hoisting equipment was serviced in August 2005, the portable hoist was serviced in Jan 2006.A gas landlords safety certificate was available dated September 2005, a gas service had been carried out in September 2005.The fire alarm system was service in November 2005. Portable electrical appliances were checked in Jan 2006. Weekly and monthly in-house checks are carried out in respect of fire prevention. Decembers emergency lighting test had not been carried out or had not been recorded. During the viewing of the premises it was noted that there were bricks, building materials and 2 glazed discarded doors in the rear garden. There was no evidence available to demonstrate that measures have been taken to prevent injury or incident due to these items. It was also noted that the top step on the first floor stairway is frayed and requires attention to prevent accidents. The kitchen was briefly assessed. Environmental Health carried out an inspection in the last two months. Few requirements were made. Only a small number of shortfalls were identified examples of which follow; the cook on duty was not aware that freezer temperatures need to be taken and recorded at least daily. The food probe is not always being collaborated monthly or if it is records are not being maintained. Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 3 x x x x x 2 2 STAFFING Standard No Score 27 3 28 4 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 3 2 x 2 Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement The registered person and manager must expand on the current care plan format, to enable instructions to be applied detailing how needs assessed will be met. Care plans must be precise detailing what the problem, concern or goal is, how this must be addressed/met, who is to do what, when and how often. Timescales of 29.12.04 and 25.08.05 not fully met. Timescale for action 16/02/06 Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 22 2 OP7 15(1) The registered person and 16/02/06 manager must ensure that any high risk areas identified, examples being tissue viability, nutritional , falls risk and moving and handling assessment outcomes / recurrent illness are included in the service users care plan. Timescales of 29.12.04 and 1/8/05 not fully met. This to include concerns in respect of behaviour, anxiety, confusion, continence promotion, diabetes, choking , activities etc. The registered person and 01/02/06 manager must ensure that accurate records are diligently and consistently maintained in respect of personal care delivered. These to confirm when residents are bathed, showered, clothes/ bedding changed, shaved, delivery of foot and mouth care, continence care etc. Timescale of 10.8.05 not being consistently met. 3 OP8 12(1)(2) (3) 4 OP9 13(2) The registered person and manager must ensure that a risk assessment is carried out for any resident who wishes to self medicate- this to include oral preparations, topical, inhalant and optical preparations. 25/01/06 Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 23 5 OP9 13(2) The registered person and manager must ensure that where medication records are handwritten; Two staff sign to verify that the medication/instructions written are correct. That the medication records contain the same detail for example allergies, doctors name as pre-printed medication records. 25/01/06 6 OP9 13(2) 7 OP9 13(2) The registered person and 25/01/06 manager must produce and maintain an up to date signature/initial list in respect of all staff who have a responsibility for medications. 01/02/06 The registered person must ensure; That the ‘medication misadministration policy’ is expanded to instruct if an incident occurs that the CSCI must be informed. That no extraneous items are kept in the medication stock cupboard. The registered person and manager must; Add to the flow chart enclosed in Dudley MBC adult protection procedures ’Safeguard and Protect’ contact names and telephone numbers for all relevant agencies. Ensure that these procedures and completed flow chart are 8 OP18 13(6) 01/02/06 Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 24 available at all times to staff. Ensure that staff read, sign and date the procedures. Up date the homes’ Access to Records procedures to provide a clear framework for residents/staff to follow if this process is required. Add to the missing persons procedure the need to report to CSCI in accordance with Reg 37. Review the violence aggression policy dated March 04. 9 OP27 18(1)(a) The registered person and manager must review/ monitor/ risk assess night staffing levels on a regular basis. The registered person and manager must ensure that a full audit of the home is undertaken in respect of radiator guards. Any radiators that are not guarded must be risk assessed until guards can be fitted. Radiators identified as not being guarded were; The ground floor parker bathbathroom. The first floor bathroom identified to the deputy during the inspection. The registered person and manager must ensure that; No personal care items ( Body sponges, crème bath solutions) are left in bathrooms. That ‘bar soap’ is not left in bathrooms. 01/02/06 10 OP25 13(4)(c) 01/03/06 11 OP26 13(3) 01/02/06 Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 25 Manage and eradicate the odour in the bedroom identified during the inspection. Provide ‘ hand wash ‘ signs in all bathrooms and toilets. 12 OP29 19(1) The registered person and manager must ensure that a full employment history complete with dates and reasons for any employment gaps is obtained for each staff member before they commence employment. 16/01/06 13 OP33 24 The registered person must implement fully the quality assurance/ monitoring package that has been purchased. This work has been much progressed. The registered person must ensure that all staff receive 6 supervision sessions in any 12 month period. Timescale of 25.8.05 not fully met. 16/03/06 14 OP36 18(2) 01/03/06 15 OP38 13(4)(c) The registered person and manager must ensure that: The first floor boiler is replaced. Engineers were on site commencing this work at the time of the inspection. 01/02/06 Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 26 16 OP38 13(4)(c) The registered person and manager must ensure that the rear garden is free from any items that may pose a risk, bricks, old glazed doors. The registered person and manager must ensure that the frayed top stair carpet second floor ( highlighted during the inspection) is made safe. The registered person must ensure that the door frame between the main kitchen and the ‘washing up’ area is adequately prepared and repainted. 01/02/06 17 OP38 13(4)(c) 25/01/06 18 OP38 16(2)(j) 16/02/06 19 OP38 16(2)(j) The registered person must: Ensure that the food probe is collaborated monthly and that records of these are made. Ensure that freezer temperatures are taken and recorded at least daily. 25/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 27 Wychbury Care Services DS0000063444.V277306.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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. 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