Inspection on 13/08/08 for Elizabeth Welsh House

This is the latest available inspection report for this service, carried out on 13th August 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elizabeth Welsh House 17/11/05

Elizabeth Welsh House 27/06/05

Elizabeth Welsh House 16/09/04

Elizabeth Welsh House 10/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Elizabeth Welsh House Pennine Way Harraby Carlisle Cumbria CA1 3QD Lead Inspector Mrs Margaret Drury Unannounced Inspection 13th August 2008 12:59 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 Elizabeth Welsh House DS0000035205.V369971.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. Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth Welsh House Address Pennine Way Harraby Carlisle Cumbria CA1 3QD 01228 606394 01228 606401 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) www.cumbriacare.org.uk Cumbria Care Mr Geoffrey Tyers Care Home 40 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (40) of places Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of 40 service users to include: up to 40 service users in the category of OP (Older people not falling within any other category) up to 8 service users in the category of DE (Dementia over 65 years of age) When single rooms of less than 12 sqm usable floor space become available they must not be used to accommodate wheelchair users, and where existing wheelchair users are in bedrooms of less than 12 sqm they must be given the opportunity to move to a larger room when one becomes available. 24th August 2006 3. Date of last inspection Brief Description of the Service: Elizabeth Welsh House is a care home registered with the Commission for Social Care Inspection to provide personal care and accommodation for up to forty residents. The home provides permanent accommodation for residents and short term intermediate care to assist people to regain their independence and return to their own homes. Elizabeth Welsh House is owned and carried on by Cumbria Care, which is a Cumbria County Council business unit. Mr Geoff Tyers is employed as the registered manager of the home. The home is located in a residential area on the outskirts of Carlisle, close to local shops and services and on transport routes into the city centre. The property consists of a purpose built two storey building set in its own grounds. Accommodation is provided as forty single bedrooms, four of which have en-suite facilities. There are accessible toilet and bathing facilities close to all the accommodation used by residents. Shared space is provided in the form of three sitting/dining rooms, a separate smoking room and a large, comfortable entrance hall. The layout of the home meets the needs of the residents living there. The home provides pleasant outdoor areas with seating for residents. The home provides 4 intermediate care beds situated on the first floor. The fees in this service range from £337.00 - £449.00 per week as at the date of the visit. There are extra charges for chiropody, hairdressing, newspapers, toiletries and taxi fares. Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This site visit that forms part of the key inspection took place over two days in August and we (The Commission for Social Care Inspection - CSCI) were in the home for a total of 8 hours. Information about the service was gathered in different ways: • Annual Quality Assurance Assessment document completed by the manager • Survey questionnaires returned by staff. • Interviews with residents, visitors and staff on the day of the visit. • Looking at any information received from other professional agencies • Details of monthly visits made by the operations manager since the last inspection. • Observations of the care and support given to those living in the home. We looked at care planning documentation to ensure the level of care provided met the needs of those living in the home and a tour of the building to inspect the environmental standards was undertaken. Medication records were examined and staff training records and personnel files were also inspected. Discussions with the manager took place on the second day of the visit about the running of the home, staffing and the dependency of those living in Elizabeth Welsh House. What the service does well: All prospective residents are fully assessed prior to a place being offered. The manager is always mindful of the needs of those already living in the home when the assessments are carried out and there is a trial period before the placement is made permanent. This is seen as a safeguard to all concerned. We spoke to some of those living in the home and they were very complementary about the staff and the help and support they received. Support and assistance was given in a warm and polite manner and comments received from residents included: “ The girls are wonderful”. “ Everyone is so kind and helpful” “ The staff are there when you need them”. Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 6 “ I’ve always been happy living here”. All those using this service have a full plan of care that is generated from the initial assessment of needs. These are updated regularly to meet any changing needs. Medication records are generally kept in an appropriate way ensuring the safety of those living in the home. Some recreational activities are provided for those wishing to join in and a varied nutritious diet is provided. Environmental standards within the home are good although some of the bedrooms are small but the home is safe, warm and comfortable. There is an experienced and well-trained staff team providing a good level of care and support. The recruitment policy means that those using this service are safeguarded at all times. Staff training is in place with training courses currently being organised by the manager when he is able to secure places. What has improved since the last inspection? What they could do better: Whist medication records and administration records are generally well kept there have been a couple of minor errors. The manager should ensure that regular audit of the records and administration of medication take place. This will ensure the safety of those living and working in the home. Staff personnel files are up to date but the individual personal development files are not. The manager should ensure, as far as possible, that these are brought up to date as soon as possible. Staff supervision is normally completed every 2 months but the records for 2 members of staff did not indicate this was so. It is important for staff development that regular meetings with the relevant line managers are scheduled 6 times a year. The staffing levels during the day are sufficient to provide a suitable level of care and support to those living in the home. However, consideration should be given to increasing the number of night staff on duty to ensure the safety of the residents at all times. Elizabeth Welsh House DS0000035205.V369971.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. The summary of this inspection report can be made available in other formats on request. Elizabeth Welsh House DS0000035205.V369971.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 Elizabeth Welsh House DS0000035205.V369971.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3, 4, 5 & 6 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All those wishing to use this service are fully assessed prior to admission. This ensures their needs are recognised and fully met EVIDENCE: Comprehensive needs assessments are completed before anyone is admitted to Elizabeth Welsh House to ensure that the home is suitable and able to meet any requirements in an appropriate manner. When we were discussing the assessment procedure the manager confirmed that he always takes into account the needs of those already living in the home before finally offering accommodation. We looked at the assessments and care plans of six residents and found the documentation to be relevant and informative. The assessment information is then used when drawing up the initial care plan after admission. No resident is admitted without an assessment/care plan received from Social Services under care management arrangements, after which the manager meets with the prospective resident and family members if this is considered appropriate. The Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 10 home has a 4-6 week settling in/trial period followed by a review to make sure the resident is happy and all their needs are being met. The manager invites and encourages prospective residents and/or their relatives to visit the home before making a decision about whether or not to take up the place. All residents have a contract with the home and with the Social Services Department. This home does provide intermediate/respite care to up to 4 residents in rooms situated on the first floor. Care staff provide support and work with outside agencies to ensure all those who are admitted for rehabilitation are able to return to their own homes as quickly as possible. We were able to speak to one lady who had been recently admitted. She had settled well but was looking forward to retuning to her home, as she had not lived there since earlier in the year. She told us that she was very appreciative of the support she was receiving and said, “ the staff are lovely and are helping me to regain the self confidence I need to go home”. Elizabeth Welsh House DS0000035205.V369971.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 7, 8, 9 & 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care of people using this service is based on their individual needs. Privacy, dignity and personal choice are promoted at all times. EVIDENCE: The care plans for 6 of those living in the home were examined during the visit. The organisation has recently introduced a new care-planning format to include a more person-centred approach to social and personal care. Over 70 of the care plans have been transferred to the new system and the remainder will be completed as soon as possible. We talked to one of the supervisors who said that the new system is much better because, ‘the residents are now much more involved in their care and many of them take an active part in the preparation and reviews’. The care plans covered such areas as mobility, diet, health needs and, in most cases their social preferences. The plans are reviewed monthly but we did note that one plan that we looked at did not appear to have been reviewed since April. It was recommended that the Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 12 manager checked a sample of care plans on a regular basis to ensure all reviews are kept up to date. Healthcare needs are met via the residents’ own doctors and the district nursing service. The staff and manager confirmed that the service has a good working relationship with all other agencies and external professional advice is available when requested. It was evident throughout our visit that the staff knew the residents very well and understood the differing needs of those living in the home. One resident told us “ I am very independent and come and go as I please, providing I tell the staff when I am going out”. Staff were seen to be polite and speaking to the residents in a warm and friendly manner. They were seen to knock on bedroom doors and waiting before entering. We looked at the medication handling, records and practices and found that staff follow the recognised corporate procedure. Medication records were, on the whole, completed correctly although we noted that any medication received mid-month was hand written on the records without the signature of the person recording the details. All hand-written entries should be signed and counter-signed by a second member of staff. This acts as a further safeguard for those using this service. It was recommended to the manager that, in future, all hand written entries are recorded, checked and signed. Controlled drugs are not kept in any great quantity but those that are currently prescribed are kept and recorded in an appropriate and safe manner. Elizabeth Welsh House DS0000035205.V369971.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Routines within the home are flexible and some leisure activities and interests are provided. This helps to give a sense of wellbeing and value to residents. EVIDENCE: The new care planning system contains information regarding the social interests and hobbies of those living in the home although in some cases this was not always evident. One of the care staff is employed as a part time activities organiser for 20 hours over a 2-week period. She organises quizzes, which are very popular, arts and crafts and bingo. Another member of staff is qualified and provides hand and nail care. When talking to the staff during the visit that confirmed that many residents just “like to sit and chat” and that they did this whenever they have the time. Pupils from one of the local schools have “adopted” the home and visit each week during term time and the residents enjoy this very much. One gentleman told us he visits the school from time to time to tell the children about his life before he came to live in the home. He also told us that he has enrolled at college to start in September and eventually hopes to write his autobiography. Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 14 Meals are served on each of the units and those residents we spoke to all confirmed that they enjoyed their meals and that they are always given a choice at each meal. We were able to speak with the cook who was happy to show us the kitchen facilities. The kitchen area was very clean and there was a very good stock of food. All supplies are purchased locally, the cook being responsible for all the ordering of supplies. The home also provides lunches for those people attending the day centre attached to the home. Elizabeth Welsh House DS0000035205.V369971.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16 & 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an accessible complaints procedure and adult protection policy in place. People using this service know their concerns will be listened to and acted upon. EVIDENCE: There are procedures in place for dealing with complaints and concerns and those residents we spoke to all said they knew who to speak to if they had any concerns to discuss. One gentleman told us, “ I have had no need to complain but you can be sure I would speak to the manager if I had”. There is a complaints log in place but it is difficult to follow as there are compliments recorded in the same document. We recommended to the manager that a new complaints book be introduced so that all concerns and/or complaints could be logged clearly. We (The Commission for Social Care Inspection) have not received any complaints since the last inspection and discussions with those living in the home confirmed that they had no complaints about the care and support they received. The home uses the corporate policy allegation of abuse and the staff we the procedure to follow. There have reported correctly and are currently Elizabeth Welsh House and procedure to deal with a suspicion or spoke to during the visit were familiar with been two recent incidents, which were being dealt with by Social Services. Version 5.2 Page 16 DS0000035205.V369971.R01.S.doc There is a copy of Social Services multi-disciplinary protocol in the home for the staff to read and there is also information regarding The Mental Capacity Act for staff to refer to. Safeguarding of vulnerable adults training has been completed by some of the care staff and others are due to attend a course in September. Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 23, 24, 25 & 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, hygienic and reasonably well maintained, helping to ensure that people live and work in a safe and comfortable environment EVIDENCE: Elizabeth Welsh House is a purpose built home set over two floors with access to the upper levels via a passenger and a platform lift. The ground floor contains a lounge/diner and residents’ rooms. All the bedrooms are for single occupancy and there are bathing and toilet facilities available nearby. There is access to the gardens and outside space. Bedrooms, although very small, are personal to each resident with pictures, ornaments and small items of furniture brought from home. There are handrails on the corridor to assist with walking around the building. Because of the size of the bedrooms there is an individual risk assessment on each door to avoid unnecessary accidents. The kitchen and laundry facilities are also situated on this floor, the laundry being well away from the kitchen area. Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 18 On the first floor there are two units comprising two lounge/ diners, residents’ bedrooms and small sitting areas providing extra space for the residents to enjoy. The corridors are wide with handrails for ease of movements between the units. This floor contains the four bedrooms designated as intermediate care rooms. These are larger than the other bedrooms in the home and used for those residents admitted from hospital for care and support prior to returning to their own homes. There are gardens for the residents to use in the summer and a sitting area at the front of the building. The home is quite well furnished and all the bedrooms have been furnished with new carpets, curtains and bed covers. The manager works with the organisation’s estates manager to ensure the building is as well maintained, as the budget will allow. Since his appointment the manager has negotiated an increase in the domestic hours and has appointed additional staff to ensure the home is kept clean and odour free. Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team have been correctly recruited and have the necessary skills and experience to provide a good standard of care to older people. EVIDENCE: Staff rotas and observations during the visit indicate that the home has a stable staff group with a range of skills and experience to provide a good level of care and support to those living in the home. There are normally 6 carers, sometimes 7, plus the supervisor and manager on duty during the day with 2 waking night staff. Considering the size of the home and layout of the building we felt that consideration should be given to increasing the number of night staff on duty. This would ensure that residents would be in safe hands at all times. Discussions with the manager confirmed that should it be necessary, such as an increase in dependency levels, an extra member of night staff would be employed. An increase in domestic hours has meant the employment of new domestic staff. We observed a warm understanding between the staff and residents and it was obvious the staff knew the residents well. The residents responded in a friendly manner and commented to us that, “the girls are lovely” and “the staff are great”. We were able to speak to several members of staff during the visit and received positive comments about working in the home such as, “ the team work well together”, “it is a lovely place to work” and “I really enjoy my job”. Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 20 The home follows the corporate policy and procedure for staff recruitment and we checked a sample of the personnel files including those of recently appointed staff. These contained all the relevant documentation to meet the National Minimum Standards including, an application form, references and a contract of employment. No new member of staff starts work until an enhanced Criminal Records Bureau (CRB) check has been completed. There is over 50 of the care staff qualified to NVQ level 2 with a further 2 staff part way through the qualification. The manager would like more staff to undertake the course but there were only 2 places available at the time. Training is ongoing but the manager advised us that it is very difficult to access places on training courses as they are allocated on a first come first served basis and very often the places are taken before he receives the information. We recommended that he discuss this situation with his line manager in an effort to ensure there is a set allocation of places available to each home. Training has been completed in the following subjects, adult protection, moving and handling and dementia care. All staff have a personal development file that is their responsibility to keep up to date. The manager, who has only recently been appointed to the home, confirmed that they are not all up to date and we recommended that this work be completed as soon as possible. Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, & 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well run by an experienced manager and in the best interests of those living there. EVIDENCE: The manager, Mr Geoff Tyers was appointed to Elizabeth Welsh House earlier this year and has recently been registered with CSCI for this appointment. He has a wealth of experience in caring for older people, having previously managed another home within the Cumbria Care organisation. His previous appointment was in a much smaller home and he confirmed that he is finding the management of a much larger establishment very different and challenging. He is working hard to bring the staff and supervisors on board with the changes he feels are necessary but he must remember that changes can only be made gradually. Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 22 He has an open style of management although one or two residents commented that they did not always see him when he is in the home. We discussed this with him and he confirmed that it was not always possible as there were times when his duties such as meetings and training took him elsewhere. He does, however have the interests of those living in the home at heart and wants only to ensure a high level of service and support is provided. He confirmed that he will, in future, ensure he is more readily available to both staff and residents. We observed his interaction with residents during our visits and found it to be warm and caring. Elizabeth Welsh House does hold personal monies on behalf of some of the people who live there and there are procedures in place with the records appropriately and adequately kept. All income and expenditure is recorded and signed by 2 members of staff with a monthly audit completed. Receipts for all expenses are held for each individual resident. An internal audit by Cumbria Council had recently been completed and all had been found to be in order. All equipment is serviced via annual service level agreements and staff training is in place in respect of fire safety. The organisation’s health and safety officer completes an annual audit highlighting any work to be completed. All risk assessments are in place, which demonstrates the health and safety of those living and working in the home are always under review. Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 17 X 18 3 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3, 4. Refer to Standard OP27 OP9 OP7 OP30 Good Practice Recommendations It is recommended that at least 1 extra member of waking night staff are employed. It is recommended that the manager conduct a regular audit of the medication records. It is recommended that the manager complete a periodic check of the residents’ care plans. It is recommended that the staff development files be brought up to date as soon as possible Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Elizabeth Welsh House DS0000035205.V369971.R01.S.doc Version 5.2 Page 26 - 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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