Inspection on 31/07/06 for Wychbury Care Services

This inspection was carried out on 31st July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 16/01/06

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 31st July 2006 07:10 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.V305877.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 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.V305877.R01.S.doc Version 5.2 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.V305877.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16/01/06 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. The weekly fees for this home range from £ 349-£364. Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector on one day between 07.10 and 16.00 hours. Prior to the inspection a pre-inspection questionnaire was sent to the home for completion and a number of resident questionnaires. The completed preinspection questionnaire together with 15 resident questionnaires were returned to aid inspection preparation and focus. Eight residents, two friends/relatives and four staff were spoken to during the inspection. The manager and service manager were involved in the inspection process. Four residents were ‘case tracked’ this process involves looking at their care and the service provided to them in detail. Three staff files were examined. Medication systems and safety were assessed together with records concerning health and safety and maintenance. The premises were randomly assessed to include the main kitchen, lounges and dining room in the main house, the garden, three bedrooms, two bathrooms and toilets, the kitchen and laundry. The main mealtime of the day, lunch was observed, as were general interactions between staff and residents’. What the service does well: The home is located in a pleasant residential area with beautiful views of countryside from most aspects. The registered persons and staff team are eager to provide a good standard of care and service to the residents in their care. Relatives and residents were complimentary about the staff saying that they are; “ Wonderful” and “kind”. The mealtime at the home was observed and found to be relaxed, staff on hand to give help. The food was well presented and appetising. Residents were complimentary the food saying; “ That was really nice”. “ Enjoyed the meal”. The staff were friendly and polite and courteous to the residents giving them choices wherever possible. One staff member is being appointed at the present time. Once she is in post there will be no staff vacancies. 68 of the staff team have achieved NVQ level 2 or above in care. The atmosphere of the home was friendly and welcoming. The home actively encourages residents’ to maintain contact with family and friends. Relatives spoken to confirmed that staff are friendly and make them feel welcome when they visit. Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 Page 6 The home generally is well maintained. The registered persons are aware of any redecoration needs and refurbishment needs and are pro-active in addressing these. Positive comments about the home were received and included; “ I enjoy all of the trips and outings”. “ All but four requirements made following the last inspection have been met. The home has been given few requirements following this inspection. What has improved since the last inspection? What they could do better: Generally the home is operating to an overall standard which is good. There are however, a number of areas where improvement or ‘fine tuning’ is needed, such as infection control regarding the laundry flooring and sink and room cleaning utensil (mop) control. Two windows on the first and second floor open wider than they should to ensure complete resident safety. Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 Page 7 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.V305877.R01.S.doc Version 5.2 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.V305877.R01.S.doc Version 5.2 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): 3,4. The overall outcome for this group of standards is judged to be good. No resident moves into the home without having had his/her needs assessed or being assured that these will be met. EVIDENCE: It was positive that 12 of the 15 completed resident questionnaires received confirmed that they had been given enough information prior to their admission to enable them to make a the decision that the home would be suitable for them. Two said that they had not but made further comments to address this to some degree as follows;” My daughter found the home for me” .” My daughter viewed the home”. There was assessment of need documentation on all four resident files viewed in the home. Where funded by a funding authority a copy of the care manager’s assessment was also available on file. Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 Page 10 It was pleasing that a written acknowledgement was on file for each of the four residents’ whose files were viewed confirming that the home could meet their needs. Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9,10. The overall outcome for this group of standards is judged to be good. Residents’ needs are set out in an individual plan. Residents’ health care needs are met. Medication is managed safely within the home. Residents feel that they are treated with respect. EVIDENCE: A care plan was in place for each of the four residents ‘’case tracked’. Three of the care plans were of a good standard, the fourth needs improvement. The manager confirmed that the three care plans that were of a good standard have been updated using a new format. The fourth one is yet to be updated but it will be soon. The only concern was that for one resident records of personal care delivery were not being recorded as they should be. For the other three records were better. One relative spoken to was very complimentary about the personal care delivered to her Dad; “ He is always smart and clean”. Residents seen generally looked well cared for. Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 Page 12 It is positive that 13 of the 15 completed resident questionnaires received confirmed that they ‘ receive the care and support they need’ always, 2 said usually. There was evidence of health care professional visits examples being the doctor, dentist, optician and chiropodist. There was evidence to demonstrate that doctors or health visitors review new residents and carry out health checks. Weight checks are done regularly. For one resident where there is concern about weight loss a referral has been made to the dietician. Certificates were available to confirm that all staff who have responsibility for medications have received accredited medication training. They have recently received further medication training. The home has an adequate medication policy which includes ordering, disposal and administration of medication and gives instruction about homely remedies and medication errors. The homes pharmacist has issued a contract to the home and carries out half yearly medication audits which is good practice. Medications are administered by a monitored dosage system. The medication and medication records concerning four residents were assessed and were found to be in order. It is positive that there were no staff initial gaps on records. The home has an adequate system for storing and administering controlled medications. All bedrooms with the exception of one has en-suite facilities all are single occupancy enhancing resident dignity and privacy. Toilet doors seen had workable locks. Toilet and bathroom doors were seen to be shut when in use. It is positive that the preferred form of address had been determined and recorded for each resident. Staff resident interactions seen during the inspection were positive. Staff friendly polite and respectful towards residents, giving them choices wherever possible. It is positive that 14 of the 15 completed resident questionnaires received confirmed that; ‘Staff listened and acted on what they said”. Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14,15. The overall outcome for this group of standards is judged to be good. Generally residents are satisfied with the daily routines and lifestyle offered by the home. Residents are very much encouraged to maintain contact with family and friends. Residents are helped to exercise choice and control over their lives. Residents are offered a wholesome diet in pleasant surroundings. EVIDENCE: It is positive that the preferred daily routines for example rising and retiring times for each resident are explored, recorded and obviously honoured wherever possible. One resident said;” I go to bed between 9.15 and 9.30 pm and get up between 08.30 and 9 am, I am happy with this”. During the inspection residents’ got up at different times up until mid morning. Activity provision has improved since the last inspection which is pleasing, this confirmed in part by feedback from resident questionnaires. 11 of the 15 completed resident questionnaires specified that there are activities arranged by the home that they can take part in always, 4 usually. Comments received about activities included the following; “I enjoy the trips”. “I chose to take part in a few”. “ There are too many sometimes”. Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 Page 14 It is fortunate that the home has its own mini bus, therefore residents can go out with staff on a regular basis. On the day of the inspection 6 residents went out in the mini bus for a ride in the country before lunch. The home produces an activity programme at the start of each month for that particular month. For the month of July activities offered included; 3rd Safari Park, 4th external exercise provider, 5th bingo, 6 external activity provider, 17,24 and 31 mini bus trip. Three of the four residents files viewed were checked to see if they were participating in activities and it was found that they all were. The home has an open visiting policy, which allows visitors at anytime time but discourages visits during meal times. Relatives spoken to were happy with the visiting arrangements. One said, “My son visits every night but Tuesday”. Another said; ”I visit once a week”. All confirmed that they were welcomed by staff. One visitor said;” I have always felt comfortable visiting here. The staff are friendly and make me feel welcome”. External advocacy information was available on the notice board in the ground floor corridor. All residents’ bedrooms held a range of personal belongings from pictures and ornaments to televisions. One resident said;” Most of the furniture in my room belongs to me, I even have my own three piece suite as my room is very big”. Resident files viewed held personal letters to them about voting processes to enable them to vote if they wish. The home has a set menu which operates over a four-week period. The menu details four meals per day, breakfast, lunch, tea and supper. A small wipe clean board is available in the ground floor corridor displaying the main meal for each day. Residents are asked the day before what they would like for the following day. They are asked each day if they would like a hot or cold option for their tea. The main mealtime of the day was observed. The meal was corned beef salad or cod roe, creamed potatoes or chips, mixed vegetables, parsley or tartar sauce followed by sponge and custard. Meals served were well presented, of good sized portions and smelt appetising. Residents were offered bread and butter with their meals. It was pleasing to see that drinks were readily available, fresh fruit juice or squash. Staff asked residents if they wanted second helpings and topped up their drinks during the meal. The dining room is pleasant. Tables attractively laid with tablecloths and table decorations. Salt, pepper and vinegar were available on all tables. Staff were on hand to give any assistance required. One resident following her meal said to a staff member; “ That was really nice”. Another said;” Enjoyed the meal, the roe was very nice”. One resident did comment however, that at times the toast is soggy in the mornings. Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 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 the following standard(s): 16,18. The overall outcome for this group of standards is judged to be good. Residents and their relatives’ complaints are listened to and acted upon. Processes are in place to enhance the protection of residents’. EVIDENCE: No complaints have been received by the home or the CSCI for over 11 months. This was confirmed by viewing the complaints log, the last complaint recorded by the home was on the 19 October 2005. The home has a complaints procedure which is on display in the ground floor corridor. It is positive that 14 of the 15 completed resident questionnaires received confirmed that; “They know who to speak to if they are not happy”. 8 of the 15 confirmed that;” They know how to make a complaint”, 4 usually and 1 sometimes. Comments were received as follow; “ My son would sort it out”, “ I let my daughter know and she would sort it out”. There have been no allegations or incidents of abuse since before the last inspection. This incident was not upheld. The home has its own in-house procedures concerning the protection of vulnerable adults. The majority of staff have received abuse awareness training. The training content was shown to the inspector by the trainer and looked satisfactory. However, it did not include awareness of Dudley MBC processes which are the ones that must be activated if an allegation or incident were to occur. Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 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 the following standard(s): 19,26. The overall outcome for this group of standards is judged to be good. Generally residents live in a well maintained, comfortable, homely environment. Improvements are needed in some areas of infection control. EVIDENCE: The home is a large detached residence comprising of the main building and coach house. It offers a number of lounges and dining space. One staff member said; “ A positive about the home is that there a number of rooms available for residents to sit in”. Views from most aspects are beautiful, of open countryside. The homes gardens have been improved to provide well maintained gardens and a large patio area with ample garden furniture. One resident said;” I like to spend a lot of time outside in the garden, I am proud of it”. Work is still on-going in the garden. There are plans to widen the paths to enable greater accessibility to all areas. Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 Page 17 The home does have some decorating and refurbishment needs such as the replacement of some carpets, the re-staining of windows in the coach house, the redecoration of landings. However, the registered persons are pro-active in this area, this demonstrated by striped walls in the conservatory and first floor landing where redecoration is being carried out. At least four bedrooms have been redecorated since the last inspection as well as corridors. Bedrooms viewed were seen to be well decorated and maintained. Generally the home was seen to be clean with no offensive odour. One visitor said; “One criteria for measuring a home is its smell. There are no bad smells here”. 14 of the 15 completed resident questionnaires confirmed that;” The home is always fresh and clean”. One answered “ Definitely” to this question. Concern was raised in a number of areas examples being; there was a lack of a hand washbasin in a first floor bathroom. Although there were written hand wash notices in bathrooms and toilets residents may not understand or be able to read these so basic signage would be better. The sink used for the laundry was stained and dirty. The laundry floor is in need of re-coating. Mop control needs tightening. Buckets and mops were not labelled with rooms to be used in. Mops were seen left in water. It is positive that the majority of staff have received infection control training. Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 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 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): 27,28,29,30. The overall outcome for this group of standards is judged to be good. Resident needs are met by the skill mix and number of staff. Residents are in safe hands. Residents’ are supported and protected by the homes’ recruitment processes. Staff are trained and competent to do their jobs. EVIDENCE: Six staff have left in the last 12 months for various reasons. However, recruitment has taken place and the home, when the last staff member commences work, will have no vacancies. Staffing is provided as follows; AM 5 carers plus a senior (manager during the week). PM As above. Night 2 carers. The home has at least two staff members who are employed to cover sickness and holidays to ensure consistency and prevent agency staff having to be used. There were no serious concerns raised about staffing levels. The home uses the Department of Health staffing tool to assess staff requirements in terms of numbers and works over hours stipulated. Care staff spoken to all confirmed that they have enough time to do their work and that they feel that there is sufficient staff in general. Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 Page 19 9 of the 15 completed resident questionnaires received confirmed; “ That staff are always available when they are needed, 6 Usually. Comments received included;” May have to wait a little while”. “ Always there”. “ Some staff cooperate more than others”. One relative said; “ The staff are lovely, really caring”. It is positive that over 68 of the care staff team have achieved NVQ level 2 or above. A number of seniors have level 3, the deputy has just completed her level 4. In general recruitment processes were seen to be satisfactory. Staff files viewed held all of the required information and evidence that the required checks had been carried out. Evidence was available on staff files to confirm that they had received induction. Skills for Care induction standards were seen within the home. The home has a training matrix to use to assess training needs. Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 Page 20 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): 31,33,35,36. The overall outcome for this group of standards is judged to be good. The home is run by a manager who is fit to be in charge. The home is run in the best interests of the residents’. Generally the financial interests of the residents’ are safeguarded. Improvement is needed concerning senior staff supervision session frequency. Generally the home the health and safety of staff and residents is promoted. EVIDENCE: The manager has been approved by the Commission as a fit person to be in charge of the home. She is not responsible for any other registered premises. The manager has just completed her Registered Managers Award and should be congratulated. She is awaiting her certificate. Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 Page 21 Staff spoken to during the inspection all confirmed that they feel supported and guided as needed by the management team. One relative said; “ The manager and seniors are all good and kind”. The home has improved considerably since the last inspection with its quality assurance and monitoring processes. A comprehensive business plan for 06/07 has been produced. The home has issued questionnaires to residents, relatives and other stakeholders to gain their views about the home and services provided. Thee have been analysed and appear to have positive feedback. The home has yet to fully instigate a process to audit service delivery within the home. Assurances have been given by management that this will be done. Generally, residents’ money held in safekeeping is secure with records maintained. Money was checked against balances for 3 residents and was found to be correct. It was identified that the hairdresser and chiropodist are not issuing individual receipts to residents as they should for clarity and compliance with the Data protection Act. There was written evidence available to confirm that 3 staff have received 2 formal, one to one supervision sessions in the last 4 months. There was not any available however, for the 1 senior case tracked. The manager confirmed that this senior has not received supervision of late and must address this. Generally health and safety is observed within the home. Records were in place to confirm regular servicing of fire and other equipment, water temperatures and gas checks. One certificate issued by a company detailed that work was needed yet there was no evidence to confirm that this had been addressed. Two bedroom windows on the first and second floors were seen to open wider than they should. Windows on all floors must be assessed and suitable, safe restrictors fitted. The only concern regarding mandatory training is the frequency of fire training received by some staff. In general other training uptake is satisfactory. The kitchen was found to be satisfactory. Environmental Health were on site at the time of the inspection training staff about new procedures and records that are now required. Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 Page 22 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 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 2 2 x 3 Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 Page 23 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 OP8 Regulation 12(1)(2) (3) Requirement The registered person and 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. One resident’s personal care records were not fully completed. 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 available at all times to staff. Timescale for action 15/08/06 2. OP18 13(6) 01/09/06 Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 Page 24 3. OP18 13(6) 4. OP26 13(3) The registered persons must ensure that abuse awareness training covers Dudley MBC Multi-agency procedures. The registered person and manager must ensure that; Provide easy to read ‘hand wash’ signs in all bathrooms and toilets to complement the written ones in place. 01/11/06 20/08/06 5. OP26 13(3) 23(2)(j) 6. OP26 13(3) 7. OP26 13(3) 8. 9. OP26 OP35 13(3) 13(6) 16(2)(l) The registered persons must ensure that a hand washbasin is installed in the bathroom on the first floor where the former hand washbasin has been removed. The registered persons must ensure that there is adequate mop control as follows; All mops and buckets must be labelled to specify the area that they are to be used in. Evidence must be available to demonstrate that mop heads are cleaned daily. Evidence must be available to demonstrate when mop heads are changed. Mop handles should be durable plastic. Mop heads must be left to dry between use. The registered persons must ensure that the double sink near to the laundry is cleaned thoroughly on a regular basis. The registered persons must recoat the laundry floor. The registered persons must ensure that the hairdresser and chiropodist issue individual receipts to the residents. 25/08/06 15/08/06 31/07/06 01/10/06 01/09/06 Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 Page 25 10. OP36 18(2) The registered person must ensure that all staff receive 6 supervision sessions in any 12 month period. Timescales of 25.8.05 and 01/03/06 not fully met. 01/10/06 11. OP38 13(4)(a) 12. OP38 23(4) 13. OP38 13(4)( c) 14. OP38 23(2)( c) The registered persons must ensure that windows on the first and second floor are fitted with restrictors. For advice contact Environmental Health and West Midlands Fire Service. The registered persons must ensure that all staff receive two fire training and two fire drill sessions in any 12 month period. The registered persons must ensure that the first aid trainer details on staff certificates how long the training certificate lasts, for example one year, three years. The registered persons must provide authentic evidence to confirm that the work identified on the MAW contractors service sheet has been completed. 01/09/06 01/12/06 01/12/06 30/08/06 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.V305877.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Wychbury Care Services DS0000063444.V305877.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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