Inspection on 25/07/05 for Wychbury Care Services

This inspection was carried out on 25th July 2005.

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 16/01/06

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 350 Hagley Road Pedmore, Stourbridge West Midlands DY9 0QY Lead Inspector Cathy Moore Unannounced 25th July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Wychbury Address 350 Hagley Road, Pedmore, Stourbridge, West Midlands, DY9 0QY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01562 885106 01562 883388 Mr David Johnson Mrs Anthea Kay 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 E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Physical Disability ( P.D). Date of last inspection 7th December 2004 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 for older people who have been diagnosed as having dementia and twelve 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 large 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 main kitchen, laundry and offices.The home offers two lifts in the main home and a stair lift in the coachhouse allowing residents to access all parts of the home. Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted as one of the home’s two statutory inspections for this inspection year. The inspection was carried out by one inspector during the hours of 07.15 and 16.00 hours. During the inspection parts of the premises were viewed which included the dining room, two lounges, three bedrooms, external aspects (External décor and the rear garden) and the impressive new hair-dressing salon. Four residents were chosen for case tracking purposes. These residents’ personal files and other records were examined. Two of the four were spoken to in detail. Ten other residents were spoken to in less detail and discussion was held with five relatives. Three staff were primarily involved in the inspection process. Three staff files were examined along with records in respect of health and safety and general maintenance. The breakfast and main meal times were partially observed. 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 are all keen to provide a high quality service to the people in their care. The homes atmosphere is warm welcoming and friendly. A number of staff have been employed at the home for a number of years providing consistency of care. The home is situated in a residential area, with views of countryside from most first floor windows. The rear garden is of a generous size, is maintained regularly and is very attractive and pleasant. There is a large patio area, a fishpond, well established trees and shrubs and horses grazing in an adjacent field. One Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 6 resident commented “ I love the garden, I can go out and walk in it when I want to”. A number of positive comments were received from relatives one said” I visit everyday except Tuesday’s. My wife is well looked after”. Another said, “ The home is fantastic, I am more than happy with my brother’s care. They are really brilliant, always changing and cleaning him”. Positive comments were also received from residents’ one said” The home is o.k. I like it here. The staff are good”. Another said “ I like it here because the people are friendly. It’s a nice place. I’ve got a terrific room, it’s a beauty. I’ve brought all my own furniture into my room, my antique furniture and my family pictures”. One resident commented “ I’ve only been in here for a while. I’m getting used to it now and am enjoying being here. I feel settled and have made friends. I like mixing with people and enjoy company”. The home must be congratulated in their recent achievement of being accredited with the Investors In People Award. What has improved since the last inspection? What they could do better: Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 7 The home must expand on their care planning process to ensure that all needs are incorporated within the care plans and that the care plans contain specific instructions to staff. Care plans must be reviewed regularly or as changes occur. Record keeping in respect of health and personal care delivery must be completed with consistency and diligence. Risk assessment processes require expansion. Risk assessments must be reviewed regularly or when risks are identified or give greater concern. Risks identified and outcomes must be reflected in the residents care plans. Staff recruitment processes require fine tuning. More attention must be paid to staff supervision. The homes newly purchased quality assurance/ monitoring package must be fully implemented. This in turn will identify shortfalls within service provision. 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 E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 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 standard(s) 2,3,4,5 The terms and conditions document lacks vital information. In general no service user moves into the home without having their needs assessed or being assured that their needs will be met. Service users in general know that their needs will be met when entering the home. Prospective service users and their relatives have an opportunity to visit and assess the quality, facilities and suitability of the home before they are admitted. EVIDENCE: A written terms and conditions document was included on the files of the residents selected for case tracking. A section was included for individuals who are funding third party charges. The terms and conditions documents did not detail the weekly fee applicable to the individual resident, who is responsible for paying the fee or who is responsible if a breach of the terms and conditions occurs. There was evidence of assessment of need processes. The documentation in respect of this had been signed by the residents concerned. Copies of care management assessments and care plans were included on the files examined. Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 10 The registered persons are fully aware of their responsibilities to ensure that they do not offer a placement to any prospective resident unless they can confirm that they can meet their full needs. A letter was included on three residents files confirming their assessed needs and that the home will meet these needs. There was however, no letter on file for (M.M). There was evidence available to demonstrate that prospective residents are offered the opportunity to visit the home to assess its suitability before they are admitted. The home has a trial period in operation for new residents. This trial period to give them time to determine the suitability of the home before their placement is confirmed. Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 7,8 Service users care plans and care planning processes are inadequate and require development. Records examined do not give full assurance that all service users health and personal care needs are being met EVIDENCE: A written care plan was included on all service users files viewed. Care plans seen are of an unacceptable quality in respect of content and instruction to staff. A number of significant needs of service users were not incorporated into their care plans. One service user (D.G) had demonstrated challenging outbursts and had three falls in the month of July, however these occurrences were not reflected in his care plan. There were no specific diabetic care plans to instruct staff on signs and symptoms to observe for or what to do if these symptoms are identified. Where risks from nutritional or tissue viability assessments has been identified there was no mention of these in care plans. Not all care plans are being reviewed as they should be on a monthly basis or when changes occur. Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 12 Records in respect of personal care delivery are not being diligently or consistently completed. One relative commented however, “ They are always changing him and cleaning him”. Risk assessments are unsatisfactory and are not being completed for concerns such as aggression or challenging behaviour. Moving and handling assessments are not always being reviewed. Falls risk assessments were seen to be non- specific. One resident (S.M) has difficulty swallowing and has been assessed as having a potential to choke. Yet there was no risk assessment available in respect of this. Evidence of some healthcare service provision was lacking particularly the chiropodist and specialist opticians for diabetics. There was evidence that all residents are being weighed regularly and that these weights are being monitored. A visiting district nurse confirmed that there was good communication between the home and her doctors practice and that she had no concerns about the care delivered to residents. One resident who is relatively independent requested that staff arrange for the doctor to see him. This was dealt with promptly. Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 12,13,14,15 Overall residents find the lifestyle in the home matches their expectations and preferences. Residents are encouraged to maintain contact with family and friends and have the opportunity to access the local community. Residents are enabled to exercise choice and control over their lives. Residents receive a wholesome, appealing balanced diet in pleasing surroundings. EVIDENCE: There was evidence to demonstrate that preferred daily routines are determined in respect of individual residents. Other preferences such as the number of pillows required, bath or shower and times of baths or showers are recorded for each resident. Activity provision is detailed on a notice board. The activity provision was varied and included visits to various places of interest in the local community and beyond. It was noted that a trip out was planned for the day of the inspection. This trip did not occur as the staff member responsible was on leave. Records to evidence individual activity participation are not being completed consistently. Visiting times are open and flexible. One relative said that she visits the home every other day, another everyday except Tuesdays. One visitor commented, “ The staff are always friendly and make me feel welcome. One resident commented “ I go to my family every Sunday for dinner”. Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 14 Bedrooms viewed held a range of residents’ personal belongings including televisions, pictures and items of furniture. One resident said “ I brought all my own furniture into my room, my antique furniture and my family pictures”. Furniture brought into the home was seen listed on individual resident inventories. Information pertaining to an external advocacy service was seen available in the home. The home has an access to records policy. Breakfast time was briefly observed. Residents had a choice of cereals, toast and hot options. A number of male residents had chosen bacon sandwiches. The main lunch time meal was observed in greater detail. Tables were attractively laid with tablecloths and serviettes. Condiments, salt, pepper and vinegar were available on each table. Sauces were offered with the meal. A choice of fresh orange juice or orange squash was offered to residents. The main meal was fish fingers with tartar sauce or salmon salad. The meals were attractively presented and served with potatoes and/or chips and peas. One resident had chosen a baked potato as an alternative. Bread and butter was provided for those who wanted this. The dining room is attractive. The atmosphere during the meal relaxed. Staff were heard giving food choices to the residents. Staff were on hand to give assistance where needed. Menus are set over a four week period. These menus detailed lunch and tea options, not breakfast or supper. Records are made of food consumed by each resident on a daily basis. Not all meals however, for example, supper are being recorded. Comments from residents on the homes food/ meal provision included “ Food generally very good”. “The food is o.k. no complaints”. “The food is not bad”. “ we have a choice at mealtimes”. Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 15 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 standard(s) 16,17 Overall service users can be confident that their complaints will be listened to and acted upon. Service users legal rights are protected. EVIDENCE: The home has a written complaints procedure in operation. The complaints procedure detailed the address and telephone number of the local Commission for Social Care Inspection office and held a 28 day deadline for responding to complainants. The complaints procedure has been produced in standard font only which may not be appropriate to all residents’ needs. The home has not received any complaints for some time. There was evidence available to demonstrate that residents have been registered with Dudley Council for them to be sent the necessary papers/ information for them to vote. Adult protection procedures and processes were not assessed during this inspection. One resident raised a concern during the inspection which was highlighted to the manager for attention, referral and investigation. Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 16 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 standard(s) 19,24 Residents live in a safe, well maintained environment. In general residents live in safe, comfortable bedrooms with their own possessions around them. EVIDENCE: Work has progressed significantly in respect of external and internal repair and redecoration. The home has had repair work carried out externally and a number of windows have been replaced. A number of bedrooms have been redecorated. At the present time decorating work is being carried out on the ground floor corridor. A relative commented positively about the redecorating work that has been carried out. A ground floor room that was not presently used for residents has been refurbished and converted into an impressive, fully fitted hair dressing salon. An excited relative proudly showed off this room. Décor in the salon is professional and attractive. It has been provided with state of the art furnishings and fixtures. Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 17 Internal decoration is still required in a number of areas. However, the management are aware of what needs doing and are attending to this by means of a programme. The manager commented that replacement of the windows in the main lounge is the next project. The rear garden is of a generous size and is well maintained. It is accessible by ramps from the inside of the building. A number of residents commented that they had enjoyed the garden during the recent warm spell. The patio area has been jet washed. The block paving in this area now looks new. Three residents bedrooms were viewed. In general these were seen to be attractive, with pleasant views from the windows. Furniture, fittings and bedding were seen to be of a good quality. All bedrooms contained residents’ own personal possessions ranging from pictures, to televisions and furniture. One bedroom (D.G’s), viewed however, did not have a lockable facility or bedside lamp, the light in the en-suite was not working and the divan base drawer did not fit correctly under the bed. Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 Residents’ needs are being met by the numbers and skill mix of the staff. Recruitment practices require further development. EVIDENCE: The home is fully staffed at the present time. The home has seven vacancies. The home employs dedicated domestic, laundry, catering and handy people. The manager was made aware that a surplus of staff are required to enable the home to accept new residents into vacant beds. There was evidence to demonstrate that the dependency levels of each resident are assessed. However, it was not clear if behaviour or other areas of concern are being included in the assessment process in determining the dependency levels. Four staff files were examined. One staff member had been allowed to commence employment with a POVA first check rather than waiting for her Disclosure. Reference letters must be reviewed to ensure that the referee enters their full name and signature and in the case of a company or official reference, that the reference form is stamped with the company name. There was only one source of identity for one staff member. Another staff member had not provided all dates of previous employment. Other than these issues staff files viewed were seen to be satisfactory. Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,38 Residents live in a home which is run and managed by a person who is fit to be in charge. Development is needed to ensure that residents benefit from the ethos of the home. Development is needed in respect of quality assurance and quality monitoring systems. Further development is needed to ensure that all staff are appropriately supervised. Overall, observance is paid to health and safety issues. EVIDENCE: The manager has been approved by the Commission as a fit person to manage the home. The manager has recently completed the required N.V.Q award and is working to attain the full registered managers award. Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 20 Evidence was available to suggest that relatives and residents are consulted with by means of meetings and other forums. This process requires enhancement to ensure that residents and relatives are given the opportunity to participate in the home’s decision making and production of policies and procedures. The home has recently been accredited with Investors In People and must be congratulated. Work has commenced on the quality assurance system, however, this is far from full completion. Staff supervision processes were seen to be in operation. The format of the supervision sessions does not include all of the required elements. There was no evidence to demonstrate that one staff member (L.B) has received any supervision to date. Overall health and safety is being observed. Maintenance and fire fighting equipment serviced as it should be with the exception of the portable hoisting and bath hoisting equipment. The Velux window in room 37 is not safe, as it opens too wide. Appropriate restrictors must be fitted to this and any other windows of this type. Mandatory training overall was assessed as being up to date or training had been arranged where there are gaps. Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 x x x x 2 x x STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 x 3 2 2 x x 2 x 2 Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5(1)(b) Requirement The registered person and manager must ensure that the residents terms and conditions documents detail the applicable weekly fee, who is responsible for paying the fee and who is responsible if a breach occurs. The registered person and manager must ensure that a written acknowledgement is given to all prospective residents confirming their needs and how these will be met by the home. 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. Timescale of 29.12.04 not 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. The registered person and manager must ensure that all service users care plans are reviewed at least on a monthly Timescale for action 25.08.05 2. OP4 14(1)(d) 01.08.05 3. OP7 15(1) 25.08.05 4. OP7 15(2)(b) ( c)(d) 25.08.05 Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 23 basis or earlier if changes occur. Timescale of 29.12.04 not met. This to include the monthly care monitoring form that is in operation. The registered person and 01.08.05 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. Timescale of 29.12.04 not fully met. This to include concerns in respect of behaviour, anxiety, confusion, continence promotion, diabetes, choking , activities etc. The registered person and 10.08.05 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. The registered person must 10.08.05 ensure that risk assessments are in place to cover all areas of concern and are specific. Examples being, choking, falls risk assessments, moving and handling, behaviour such as confusion and aggression. These risk assessments must be carried out on a regular basis for example after aggressive outbursts, falls etc. and be reflected in the residents care plans. Version 1.40 Page 24 5. OP7 15(1) 6. OP8 12(1)(2) (3) 7. OP8 13(4)(c ). Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc 8. OP8 12(1) 13(4)( c) 9. OP8 12(1)(a) (b) 13(4)( c) 10. OP8 12(1)(a) (b) 13(1)(b) 12(1)(a) (b) 13(1)(b) 11. OP8 12. OP12 16(2)(n) (m) 13. OP12 16(2)(n) (m) 16(2)(i) SCH 4 (13) 16(2)(i) SCH 4 (13) 14. OP15 15. OP15 16. OP16 22(2) The registered person must ensure that nutritional assessments are carried out on a regular basis and that these assessments are dated. The registered person and manager must ensure that tissue viability assessments are carried out on a regular basis, particularly for those residents which have previously been assessed as being at risk or new concerns are identified. The registered person and manager must ensure that all chiropody input is recorded consistently. The registered person and manager must ensure that all residents have access to all healthcare services on a regular basis. This to include a full annual health care review from their doctor. The registered person and manager must ensure that activity programmes are accurate and that all activities are available as stated. The registered person must ensure that records relating to individual activity participation are completed consistently. The registered person and manager must ensure that all meals are detailed on the homes menu, to include a minimum of breakfast, lunch, tea and supper. The registered person must ensure that all food/meals consumed by the individual resident are recorded, this to include a minimum of breakfast, lunch, tea and supper. The registered person and manager must ensure that the complaints procedure is appropriate to the needs of the 10.08.05 10.08.05 10.08.05 25.08.05 10.08.05 10.08.05 10.08.05 05.08.05 25.08.05 Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 25 17. OP18 13(6) residents, examples being, produced in large print and pictorial formats. The registered person and manager must provide the CSCI with the outcome of the concern raised by resident (D.G) and any records of Socical Service department input and internal investigations/action taken. The registered person and manager must ensure that (D.Gs) bedroom is provided with: A lockable storage facility. A bedside lamp. That the light in the en-suite is in good working order. That the divan drawer is mended. 20.08.05 18. 19. OP24 16(2)( c) 05.08.05 20. 21. OP27 18(1)(a) The registered person and manager must ensure that the dependancy ratings of the residents are accurate and precise at all times. Behaviour, aggression and all other factors must be taken into consideration when assessing indiviual residents dependancy levels. The registered person must ensure that no staff are allowed to commence employment without firstly receieving a full enhanced disclosure / POVA list check. If untoward circumstances arise when staff may be needed to commence employment on a POVA First check rather than the full CRB/POVA list check then the Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 26 25.08.05 22. OP29 19(1) 25.07.05 CSCI must be informed. 23. OP29 19(1)(c ) The registered person and manager must review the referee letter. All referees must be requested to print and sign their name and include the company stamp or other identity on the letter. The registered person and manager must ensure that two official sources of identity are obtained in respect of each staff member before they commence employment. One of these must detail their current address. 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. The registered person and manager must promote a system to encourage service users to be actively involved in the decision making of the home. Service users must be given the opportunity to be involved in the production of the homes policies and procedures and other issues to ensure that the operation of the home creates an open, positive and inclusive atmosphere. Timescale of 29.02.05 not fully met. The registered person must implement fully the quality assurance/ monitoring package that has been purchased. The registered person must ensure that supervision sessions incorporate all elements of standard 36.3. The registered person must 15.08.05 24. OP29 19(1) 25.07.05 25. OP29 19(1) 25.07.05 26. OP32 12(5)(a) 25.09.05 27. OP33 24 10.12.05 28. OP36 18(2) 25.08.05 29. OP36 18(2) 25.08.05 Page 27 Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 30. OP38 23(2)( c) ensure that all staff receive 6 supervision sessions in any 12 month period. The registered person and manager must ensure that all hoisting equipment, including bath hoisting equipment receieves a service. Evidence that these services have been carried out must be provided to the CSCI. 10.08.05 31. OP38 19(4)(a) 32. OP38 13(4)(a) 33. OP38 13(4)9 c) All hoisting equipment must then be serviced every six months. The registered person and 05.08.05 manager must ensure that a documented risk assessment is carried out in respect of the expectant worker. The registered person and 05.08.05 manager must ensure that the carpet join in the corridor leading to the hair dressing salon is made secure. The registered person and 25.08.05 manager must ensure that: The work identified in the electricians report dated the 19/07/05 is completed. The first floor boiler is replaced. 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 Good Practice Recommendations Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection Mucklow Office Park West Point, Mucklow Hill Halesowen 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. Extracts may not be used or reproduced without the express permission of CSCI Wychbury E55 S25023 Wychbury V240217 250705 Stage 4.doc Version 1.40 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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