Care Home: St Anne`s (Dewsbury 2)

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What the care home does well Service users` needs are assessed before they are offered a place at the home. And service users are welcome to have `trial visits` to help them make a choice about moving there. A well trained, supervised and committed staff team support service users to live their chosen lifestyle within a risk management framework. Service users are supported to be involved in the day-to-day running of the home and to take part in community based activities. Service users are aware of how to make a complaint. The procedure is available in words and symbols. And is discussed at service users meetings. What has improved since the last inspection? Risk assessments are kept under review and daily records relating to the delivery of the service users` plan of care are maintained. What the care home could do better: The coding system on the home`s medication administration record sheets should be clearer so that it`s evident what action has been taken. The home`s policies and procedures should be in suitable formats to enable the service users to have an understanding of them. Some areas of the home need to be refurbished and furniture replaced, so that it provides a more comfortable and pleasing environment and so that hygiene standards can be maintained. The home`s complaints procedure should include up-to-date contact details of the Commission for Social Care Inspection. CARE HOME ADULTS 18-65 St Anne`s (Dewsbury 2) 13 Birkdale Road Dewsbury West Yorkshire WF13 4HG Lead Inspector Jacinta Lockwood Unannounced Inspection 19th March 2007 11:30 St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Anne`s (Dewsbury 2) Address 13 Birkdale Road Dewsbury West Yorkshire WF13 4HG 01924 459878 01924 459878 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) jenkinlodge@st-annes.org.uk St Anne`s Community Services Mrs Lesley Murphy Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (15) St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can accommodate 10 service users at Temple Road and 5 service users at Birkdale Road 21st February 2006 Date of last inspection Brief Description of the Service: Temple Road is a care home providing care and accommodation to ten people with enduring mental health problems. It is purpose built and owned by St Anne’s Shelter and Housing Action. The home is situated on the outskirts of Dewsbury and has two floors. All bedrooms are single and there are sufficient communal facilities to incorporate a choice of lifestyles for service users. Birkdale Road can accommodate up to five service users. It is situated a few miles from Temple road. It is a converted private dwelling and all rooms are single. The Commission were informed that as at 21.02.07 the scale of charges were £272.10 to £288.69. Information about the home in the form of a Statement of Purpose and Service User’s Guide, together with the latest Commission for Social Care Inspection report are available form the home. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection, one inspector carried out an unannounced visit to the service at Birkdale Road and Temple Road, Dewsbury, on 16 March 2007. The visit started at 11.30am and ended at 5.10pm. During the course of the visit the inspector spoke to five service users and five members of staff, including the deputy manager. The inspector also looked at a range of records including, for example, care plans, risk assessments, medication, food menus, complaints record, accident and incident records, staff training and supervision records, and a sample of maintenance documentation. Observations were made and a tour of the premises carried out. To enable service users, relatives and health and social care professionals to comment on the service provided surveys were sent out to all the service users living at the home. Surveys were also sent to the next of kin of two service users ‘case tracked’ as part of this inspection and to health and social care professionals involved in their care. At the time of writing ten service user surveys had been returned. No surveys were received from next of kin or health and social care professionals. The inspection findings are also based on information received about the service, for example, accidents and incidents notified to the Commission, as well as a pre-inspection questionnaire completed by the manager prior to the visit. The inspector would like to thank all those involved for their time and hospitality throughout the inspection. What the service does well: Service users’ needs are assessed before they are offered a place at the home. And service users are welcome to have ‘trial visits’ to help them make a choice about moving there. A well trained, supervised and committed staff team support service users to live their chosen lifestyle within a risk management framework. Service users are supported to be involved in the day-to-day running of the home and to take part in community based activities. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 6 Service users are aware of how to make a complaint. The procedure is available in words and symbols. And is discussed at service users meetings. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users’ needs are assessed before they are admitted to the home. EVIDENCE: Before a service user is offered a place at the home, a care needs assessment, including a risk assessment, is obtained from the service user’s social worker. Staff from the home complete a pre-admission assessment and the information forms the basis of the service user’s support plan. Service users are offered a trial visit, which provides them with an opportunity to meet other service users and staff. The visits can include a lunchtime and evening visit and then over-night stays. These take place at the service user’s pace. Nine service users returning surveys confirmed that they were asked if they wanted to move to the home and ten said they were given enough information about the home before they decided to live there. Although one service user reported not having a choice of home, their family had been consulted and the service user who trusted their judgment reported “I have been happy here”. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 9 One service user explained “I was given a thorough interview outlining the home’s procedures and my responsibilities whilst living here”. It was also evident from records seen that pre-admission assessments and visits take place. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ assessed and changing needs and personal goals are reflected in their individual plan and the service user is involved in reviewing these. Service users make decisions about their lives with assistance, as needed and are supported to take risks as part of an independent lifestyle. The home’s policies and procedures are not available in a formats suited to the needs of service users. EVIDENCE: Personal support plans and risk assessments were available for service users case tracked as part of this inspection. One service user’s plan provided an excellent level of detail to inform support staff and to provide consistency of care to the service user. Service users confirmed that they were involved in reviews of their person centred plan. And it was evident that staff support service users to achieve their objectives. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 11 Service users make decisions about their lives with assistance as needed. And are involved in reviewing the care and support they receive. Service users reported that they ‘always’, ‘usually’ or ‘sometimes’ make decisions about what they do each day. And during the day, in the evening and at weekends they can do what they want to do. Service users said they were supported by staff and made choices about their lives. It’s evident that service users are supported to take risks as part of an independent lifestyle and that, where there are concerns about their safety, staff take appropriate action. Risk assessments were available for a range of activities related to the service users’ health and welfare so that risks and hazards are minimised. Standard 10 was assessed to follow up a previous recommendation about making the home’s policies and procedures available in a format suited to the needs of service users so that they can understand them. This has yet to be actioned. This recommendation is carried forward within this report. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users take part in a range of appropriate activities within the local and wider community. They are supported to maintain personal and family relationships. And their rights and responsibilities are recognised and respected. Service users are offered a healthy diet. EVIDENCE: Staff reported that family are welcome to visit the home and some do. It was also evident from records and discussion with service users that they maintain links with family, friends and the local and wider community. They have bus passes and use local transport to get around. Service users make use of the local pubs, shops, restaurants and the local leisure facility either in the company of staff, by themselves or with friends. Some service users attend day centres. And within the house service users can take part in arts and St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 13 crafts. At the time of the visit, one service user was doing some artwork. Service users spoke of outings to places of interest, which they chose. One service user said “We are encouraged to have a structured routine, for example, attending groups or courses. We also have responsibilities within the house, for example, cooking meals, cleaning our rooms, clothes washing and keeping the sitting room tidy”. Service users were observed to make themselves something to eat and drink and where staff assistance was needed this was provided in a supportive and respectful manner. It was evident from observation that service users have a choice of food at mealtimes. And service users confirmed that they enjoyed the food. Service users are encouraged to be involved in menu planning, shopping and cooking a meal for fellow service users. A service user said this was something she enjoyed doing. Menus show that a well-balanced diet is provided and fresh fruit was available for service users to help themselves. Service users’ privacy is respected and they are offered a key to their private accommodation and to the front door of the home. This was confirmed through observation and discussion with a service user. It was evident from records and discussion with service users that they are able to visit their chosen place of worship with staff support if necessary. One service user said that life was “free and easy” at the home. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and require. Their healthcare needs are met. And they may self-administer their medication, if they wish, within a risk management framework. EVIDENCE: Service user support plans contain useful and detailed action plans, highlighting the strengths and needs of service users. Staff complete daily objective sheets, which help them to monitor the health and well-being of a service user. There was evidence in service users’ records that staff support service users to attend healthcare appointments, where necessary. Evidence was also seen that service users receive additional specialist support and advice from healthcare professionals where appropriate. One service user reported “I have a structured weekly routine which was initially supported by the St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 15 suggestions of my Occupational Therapist. I also have the support of my key worker”. Service users confirmed that they received their medication when they needed it. The home’s medication policy and procedure notes that service users should be encouraged and supported to retain, administer and control their own medication within a risk management framework. Risks assessments were available, and although staff administer most service users’ medication, where a service user is going to be absent from the home, arrangements are made for the service user to be given a supply of medication. Medication samples were checked and generally reconciled with records held. Some coded entries on the MAR (Medicines Administration Record) sheet were confusing and as discussed with the deputy manager, action should be taken to ensure clear medication records are maintained. A recommendation about this is made within this report. Where a medication error was notified to the Commission, the service provider took appropriate action and the member of staff concerned received training and supervision. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel their views are listened to and acted on. Service users are protected from abuse. EVIDENCE: The majority of service user surveys noted that staff ‘always’ listened and acted on what the service user said. Three service users reported that they ‘sometimes’ did. Service users are aware of how to make a complaint and one service user reported that staff, “particularly (key worker) are very easy to talk to and always willing to listen if any problems arise”. The home maintains a record of complaints, which shows that action is taken to address these. The complaints procedure is available in words and symbols and also discussed in meetings with service users. The procedure should, however, be updated with the contact details of the Commission. A recommendation about this is made within the report. Within the last 12 months, there have been six substantiated complaints. Records show that action was taken to address these. The home has a robust adult protection procedure in place and staff receive adult protection training. Staff gave good responses to questions asked around the protection of vulnerable adults. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 17 Service users spoken with reported feeling safe and supported by staff. Three service users returning surveys reported that staff ‘usually’ treated them well; seven service users reported that staff ‘always’ treated them well. One said that “Staff always do their best and help me”. Where there is a risk of service user to service user abuse there was a risk assessment in place and evidence that the service user’s behaviour had been addressed at review and in correspondence with the service user concerned. Records of service users’ finances were clear and well maintained. These are checked on a daily basis. And service users sign the record upon receipt of any monies. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is comfortable and suits the needs and lifestyles of the service users living there, but some refurbishment work is needed to improve the environment. EVIDENCE: The home, which was clean and fresh, had no unpleasant odours. Service users reported that the home is ‘always’ or ‘usually’ fresh and clean. Both staff and service users are involved in keeping the home clean and tidy. Both houses, though different in design and layout, provided a comfortable environment for service users. One lounge at Temple Road which contained a number of potted plants cared for by one of the service users, provides a quiet area for service users. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 19 Some parts of the home are showing signs of wear and tear. Previous recommendations about replacing some furniture have yet to be addressed, but the inspector was informed that the suite was due to be replaced, together with the lounge carpet. The plastic coating to the grab rail in a first floor toilet at Temple Road was cracked or missing and should be repaired or replaced to ensure standards of hygiene are maintained and the risk of infection minimised. The inspector was informed and it is positive to note that refurbishment of the kitchen, including the damaged boiler casing, at Birkdale Road is to take place this financial year. A recommendation about the environment is repeated within this report. Service users’ private accommodation reflected their personal tastes and interests and contain lockable furniture. Door locks are also in place on service users’ private accommodation. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A committed staff team supports service users whose individual and joint needs are met by staff who are appropriately trained and supervised. Service users are supported and protected by the home’s recruitment practices. EVIDENCE: St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 21 It was evident from records, discussion with staff and observation that staff are committed and supportive towards the service users. Staff have an individual training profile and they spoke positively about the training they receive. Staff training includes, for example, induction under the Common Induction Standards, adult protection, health and safety, food hygiene, emergency aid, movement and handling, person centred approaches and promoting equality and diversity in practice, as well as NVQ (National Vocational Qualification) training. Where a concern was identified about staff performance in relation to medication (see Personal and Healthcare Support above), it was evident from supervision and training records that this was addressed. Staff confirmed and records show that they receive regular supervision regarding their work. Supervision records were clear and well maintained. Through discussion with a member of staff, it was evident that relevant checks are carried out before a person begins to work with service users and that training and supervision forms part of the induction process. A representative of the Commission carried out an audit of St Anne’s staff recruitment records on 12.04.06. Although recommendations were made, the audit found good practice for the recruitment of staff. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39. 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care home is well managed. Service users views are sought during meetings and through the home’s annual quality assurance audit. The health, safety and welfare of service users is promoted and protected. EVIDENCE: The registered manager was not at the home on the day of the inspection. However, staff spoke positively about the home’s management who it was said was “really supportive” and “approachable”. Staff felt there was good communication within the team. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 23 It was evident that service users’ views are sought through meetings and through the home’s annual quality assurance process. One service user reported that “The carers always listen to service users and then review the situation as a whole”. From survey information, it’s clear that staff listen and act on what service users say. The inspector was informed that quality assurance surveys had recently been sent out. From records and discussion with the home’s deputy manager it was evident that health and safety checks are carried out and equipment is serviced as required. Accident and incident records are maintained and reported as required. Staff receive fire safety training and service users are encouraged to be involved. And fire safety is discussed at service user meetings. The home has a fire safety risk assessment in place. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 X X 3 x St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 26 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 YA6 Good Practice Recommendations Risk assessments should be reviewed at least six monthly or more frequently if needed. A daily entry should be recorded in the service user’s care file. 2. 3. 4. 5. 6. 7. 8. YA8 YA20 YA20 YA22 YA24 YA27 YA30 Policies and procedures should be in suitable formats to ensure the service users have an understanding of them. Action should be taken to ensure that a clear coding system is used on the Medicines Administration Record. A signatory sheet for staff with responsibility for administering service users’ medication should be maintained. The home’s complaints procedure should include the Commission’s up-to-date contact details. Refurbishment work should be completed. And damaged furniture replaced. The toilet should be replaced. This was not assessed at this inspection. Plastic coating to a grab rail in a first floor toilet should be repaired or replaced to maintain good hygiene standards. St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Anne`s (Dewsbury 2) DS0000026352.V334271.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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