CARE HOMES FOR OLDER PEOPLE
Whincroft 18 Glen View Road Burnley Lancashire BB11 2QN Lead Inspector
Mr Jeff Pearson Unannounced Inspection 09:30 5 & 6 October 2006
th th 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 Whincroft DS0000061077.V309362.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. Whincroft DS0000061077.V309362.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Whincroft Address 18 Glen View Road Burnley Lancashire BB11 2QN 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) 01282 453158 01282 425983 Mrs Linda Jane Harris Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Whincroft DS0000061077.V309362.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The staffing of the establishment shall, until further notice continue to be - The registered provider/manager to work in the home on a full time basis. 8:00 am - 10:00 pm 3 x care assistants (one designated as in charge in the absence of the registered provider/manager) 10:00 pm - 8:00 am 2 x waking watch care assistants (one designated in charge) Cook hours = 54 per week Cleaner hours = 35 per week Date of last inspection 7/01/06 Brief Description of the Service: Whincroft is a family run care home, offering 24 hour personal care and accommodation to 24 older people. The house is a semi-detached property located in a residential area on a fairly busy road on the outskirts of Burnley. There are attractive enclosed gardens, accessible to residents, on-street parking and a bus stop outside the home. On the upper ground floor there is a lounge with conservatory, two dining rooms and seating in the entrance hallway. There is a shared lounge and four self-contained units on the lower ground floor. Various aids are provided to help with mobility and independence, such as hand rails and facilities for disabled people in bathrooms. Bedroom accommodation is on three levels, on the lower and upper ground and first floors. There are 16 single and 4 double rooms, 11 bedrooms have en-suite facilities. Some of the rooms (units) are fitted with kitchenettes. Starlifts are available, to help residents to access first floor and lower floor bedrooms. The home provides recreational activities and outings. At the time of this inspection visit the range of fees was £324.50 to £378.00 there were additional optional charges for hairdressing, chiropody and toiletries. . Written information about Whincroft was displayed outside the homes office. Whincroft DS0000061077.V309362.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Whincroft on the 5th and 6th of October 2006. The visit took 11½ hours and was carried out over 1½ days by one inspector. There were 23 residents accommodated. Prior to the inspection visit, survey forms were sent to the home for the residents and their relatives/representatives to complete. Eleven were received from residents, none from relatives/visitors. Information was gathered from a pre inspection questionnaire completed by Mrs Harris, registered provider. The files/records of 3 residents were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of residents. During the inspection, the residents, homeowners, staff and a visitor were spoken with. The records of the most recently recruited staff were looked at. Some policies and procedures were seen. A tour of the home was carried out. What the service does well:
Whincroft had a welcoming and supportive atmosphere. The staff were friendly and enthusiastic. One resident said “It’s a brilliant place, I have nothing but praise for it, if you need anything, you only have to ask and it will come to you” another wrote “Whincroft is wonderful. Just like a 1st class hotel” Routines in the home were fairly flexible, so people had some freedom in how they spent their time. The residents were mostly satisfied with the activities and entertainment provided at the home. They expressed an appreciation of the food saying “we have a choice at every meal” “The food is marvellous” “They always make us a good do on our birthday, I had a barbecue” One resident wrote “The food is very plentiful, excellent quality and very well cooked and served” Visiting times were flexible so friends and relatives could call at different times, the residents could see people in private. A relative said they were always made to feel welcome at the home. The residents appreciated the staff and homeowners; relationships between everyone in the home were good. Residents described staff as “always very kind, patient and helpful” and “Staff are grand, very obliging and very pleasant” Of the managers, one resident said “they put themselves out for
Whincroft DS0000061077.V309362.R01.S.doc Version 5.2 Page 6 you” another wrote, “they have worked so hard since they came, they are super people” The home was clean and fresh smelling. The communal areas were nicely decorated and furnished in a homely way; the gardens were attractive well maintained and appreciated by the residents. There was a good approach to staff training, more than half the carers had NVQ (National Vocational Qualifications) in care and training was generally being given high priority. What has improved since the last inspection? What they could do better:
To find out and respond to people’s needs, abilities and any agreed limitations, the assessment system needed to be further developed. The resident’s individual care plans still needed to include full details of all their health and social needs and how they are to be met, to ensure staff know exactly what to do for each person. Whincroft DS0000061077.V309362.R01.S.doc Version 5.2 Page 7 Medication management, policies, practices; recording systems and assessments needed further attention for the protection of residents and staff. Residents group discussion/meetings should be introduced as an activity, to provide people with the opportunity to be consulted, make suggestions and be kept informed about things happening in the home. More thought should be given to providing suitable, interesting activities. Two of the bathrooms would benefit from refurbishment (one should be relocated) to provide more suitable facilities for the residents. To provide a safer environment for the residents, some radiators still needed covering. Confirmation was needed from various agencies, to show the alterations including the new conservatory, met with their requirements. The protection/abuse procedures needed changing to provide proper clearer instructions for staff, to make sure they do the right thing. Staff then needed to be made aware of the updated procedures. For the protection of the residents, staff recruitment practices must be improved to make sure people are properly checked out, before they start working tin the home. The quality assurance system still needed more work to make sure everyone is consulted and to show plans are being made to make improvements for the benefit of the residents. 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. Whincroft DS0000061077.V309362.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 Whincroft DS0000061077.V309362.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): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had been assessed prior to moving into the home, to make sure their needs and wishes could be met. EVIDENCE: The records of the three most recently admitted residents showed assessment, and initial care plan information had been obtained from Social Services. The home had a new format for assessing people; this covered various health and social care needs and abilities, however, communication needs had not been fully considered. Senior staff on duty said the homeowner had been out to assess people prior to them moving in. Most new residents had received letters assuring them of a place at the home. Comments from most residents completing surveys; indicated they had received enough information about the home before they moved in. Service user guides were seen in a number of residents’ rooms. One resident
Whincroft DS0000061077.V309362.R01.S.doc Version 5.2 Page 10 commented that she occasionally looked at the guide for reference. It was advised the service user guide be reviewed and updated, to include the requirements of the amended regulations. Intermediate care is not provided at Whincroft. Whincroft DS0000061077.V309362.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans did not provide enough details to fully address the residents’ health, personal and social care needs. Medication management practices needed some attention for the protection of the residents and staff. Support with personal care was provided sensitively in a way which promoted the resident’s privacy and dignity. EVIDENCE: Some residents spoken with had an awareness of their care plans and contents, some had signed in agreement with them. A new care planning system had been introduced. Senior care staff spoken with, considered care plans were much better, as they include more details. Records showed reviews were being carried out monthly. Care plans seen were not precise in detailing the assistance to be provided, for example, assistance with bathing and dressing. This lack of precise directions to staff meant that there was the potential for inconsistencies to occur in the care/support given. An agreed
Whincroft DS0000061077.V309362.R01.S.doc Version 5.2 Page 12 limitation had not been included in one care plan. The majority of residents’ surveys indicated that they ‘always’ receive the care and support they needed, those spoken with made positive comments about the care and attention at Whincroft. The residents’ surveys indicated they always get the medical support they needed. The new care plan system promoted assessment of health care needs, such as pressure area care, nutritional needs, continence and risk factors. There were records of residents receiving attention from health care professionals, such as District Nurses and GPs. Staff responsible for administering medications, had recently completed accredited training and were awaiting results of the examination. Medication management policies procedures were available. Storage was satisfactory, new facilities had been had been provided. Records and stock were checked as part of ‘case tracking’ were mostly satisfactory, there were some discrepancies, for example, one persons medication had been discontinued but not it was not recorded as such, also some ‘when required’ medications were not entered onto the medication records. There were no individual protocols for ‘when required’ and ‘variable dose’ medication. One resident having some involvement with self-administering medication, had not been properly assessed for this. Residents spoken with felt they were “treated with respect”. Staff were observed to promote privacy and dignity when assisting with personal care and support. A system was in place which linked residents to a named member of staff, who was responsible for overseeing aspects of their care “she helps me with my hair and nails” confirmed one resident. Screens were available in shared rooms. People’s preferred term of address was recorded in their care plans. A senior member of staff commented, “We treat people as we would wish to be treated ourselves” There was a telephone for residents in the entrance hall way and a mobile handset was available to so people could make/receive calls in the privacy of their rooms. Whincroft DS0000061077.V309362.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents had a degree of independence, opportunity to take part in activities, make choices and decisions and keep in touch with families and friends. The catering arrangements were sufficient in providing for the residents tastes, choices and diet. EVIDENCE: Routines in the home appeared flexible, for example, the residents said they could get up and go to bed when they wished and do “whatever they wanted”. Peoples’ interests had been recorded in their care plans. There had not been any residents meetings held recently, but people had been consulted individually about matters which affected them. An activities programme for the month of September was displayed in the home; this was due to be updated. Residents spoken with said there was usually something planned each afternoon. Most were generally satisfied with
Whincroft DS0000061077.V309362.R01.S.doc Version 5.2 Page 14 the activities on offer, which included dominoes, music, books, DVDs, movement to music exercises and visiting entertainers. Newspapers were delivered each day and the mobile library had recently called at the home. Three residents surveys indicated activities were ‘usually’ suitable and three ‘sometimes’. The residents had been encouraged to bring their own personal possessions and furniture with them, some were managing their own affairs; relatives were supporting others. There was information on display in the home about advocacy agencies. The visiting arrangements were outlined in the homes guide. Residents spoken with said they could have visitors at anytime. One visitor spoken with, said she was always made welcome at the home. Some of the residents were getting out and about with support from families and friends. All the residents spoken with said they were happy with the quality, quantity and choice of meals provided, this response was also reflected in the majority of residents surveys. Choices were being offered within each course. Most people had breakfast served in their bedrooms. Hot and cold drinks were provided throughout the day and fruit squash was available in the main lounge/conservatory. The dining rooms had been upgraded to provide more pleasant eating areas for the residents. Place settings were enhanced with individual platters and table decorations. New dining tables had been ordered. The meal times observed were unhurried and relaxed, staff were seen to be courteous and attentive when serving meals. Whincroft DS0000061077.V309362.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems and procedures were in place to provide for the management of complaints. Safe guarding adults policies and procedures, were not robust enough to fully protect the residents. EVIDENCE: The residents spoken with said they had ‘no complaints’, but had an awareness of the complaints procedure. The complaints procedure was included in the home’s guide and met with the National Minimum Standards and Regulations. There had not been any recent complaints made at the home, but complaints recording systems were in place. The management of complaints was discussed with Mrs Harris, registered provider. It was suggested systems be developed to make sure any minor issues are properly dealt with. Some staff had covered protection and abuse matters as part of NVQ (National Vocational Qualifications) training. Staff spoken with said they had recently had protection of vulnerable adults training at the home. The protection from abuse policies had recently been revised. But they did not cover all relevant matters, for example that abuse may be caused by people other than staff. The referral procedures seen did not provide appropriate instructions, for example, no reference was made to reporting incidents, allegations, or suspicions in the first instance, to Social Services or Public Protection. Senior staff spoken with did not have a clear understanding of the correct action to be
Whincroft DS0000061077.V309362.R01.S.doc Version 5.2 Page 16 taken regarding allegations, incidents, or suspicions of abuse. There were no clear policies and procedures for reporting bad practice (whistle blowing) Whincroft DS0000061077.V309362.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The accommodation provided the residents with an attractive and ‘homely’ place to live. EVIDENCE: The residents spoken with were satisfied with the accommodation provided including their bedrooms; they made positive comments about the improvements in the home. A large conservatory extension had been built on the main lounge; this had greatly enhanced the living space for the residents. The lounge and dining rooms had been decorated and new carpets fitted. Some bedrooms had also been redecorated. Chair lifts had been fitted on two staircases. There was no documentation to show the conservatory met the requirements of the fire authority or local authority building department, or
Whincroft DS0000061077.V309362.R01.S.doc Version 5.2 Page 18 that the chairlifts met with fire regulations. Not all the radiators in the home had been covered. Generally the bathrooms and toilets provided for the residents’ needs, but one bathroom was not being used due to its location being near the front door and the first floor bath was not suitable for some people. The home was found to be clean and free from unpleasant odours, all the residents completing surveys, indicated the home was always clean and fresh. Appropriate laundry equipment was available. Liquid soap was provided in bathrooms and toilets. Most staff had undertaken infection control training. Whincroft DS0000061077.V309362.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Induction training and staff development helped promote competent support and care for the residents. Staffing levels were satisfactory in aiming to ensure the resident’s needs are effectively and safely met. Recruitment practices did not sufficiently promote the protection of the residents. EVIDENCE: Residents spoken with were complimentary about the staff team. The majority of residents completing surveys, indicated staff were ‘always’ available when they needed them. Staff rotas and records of hours worked, showed that appropriate care staffing levels were in place. Arrangements were in place to cover cleaning duties. Records were seen of completed and ongoing induction training, new, unqualified staff were being supported to start NVQ training as a matter of course. Records of training showed staff development was ongoing. Copy certificates were available on staff files. Discussions with staff confirmed various training courses were provided and staff meetings were being held. More than 80 of the carers had NVQ (National Vocational Qualifications) in care, level 2. Some carers were to enrol on NVQ level 3 and senior staff were
Whincroft DS0000061077.V309362.R01.S.doc Version 5.2 Page 20 considering undertaking NVQ level 4. Some specialised training, such as dementia care was being planned for. Two staff were working in the home on a ‘trial period’ without appropriate POVA (Protection Of Vulnerable Adults) register and CRB (Criminal Record Bureaux) clearance checks, or written references. The recruitment records of the two newest employed staff were found to have discrepancies. For example, one had only one written reference and another had no evidence to show a POVA clearance check had been obtained, prior to receiving CRB clearance. Whincroft DS0000061077.V309362.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration arrangements, promoted the smooth running of the home for the benefit of the residents and staff. Quality assurance systems were not sufficient in reviewing and developing the home. Safeguards were in place to promote health and safety of residents, visitors and staff. EVIDENCE: The atmosphere at Whincroft was found to be relaxed, supportive and welcoming. The residents and staff expressed an appreciation of the homeowners; everyone seemed to get on well together. Mrs Harris had several years experience of managing a care home and had completed NVQ (National Vocational Qualifications) level 4 and the Registered Managers
Whincroft DS0000061077.V309362.R01.S.doc Version 5.2 Page 22 award. She had continued to update her knowledge and skills by attending training in medication, fire safety and infection control. Systems for monitoring the quality of the service remained informal. Residents’ and staffs’ views had been obtained during various discussions and meetings. Some questionnaires had previously been given out. Mrs Harris said they were proposing to start a more formal process of collecting information, and development planning. The homes’ guide included some information about financial matters. Records seen indicated accountable systems were in place to manage residents’ pensions, monies and charges and payments. Secure storage was available. The home was found to be free from any obvious hazards to health and safety. The pre-inspection questionnaire showed equipment had been serviced and that installations and maintenance checks were ongoing. Records were seen of various checks, a fire drill had been carried out in October, and an electrical wiring certificate was seen for the conservatory. Several radiators were still in need of suitable covering. Training in safe working practices was ongoing, or being arranged. Health and Safety risk assessments had been completed and health and safety policies were available. Whincroft DS0000061077.V309362.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Whincroft DS0000061077.V309362.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) 12(a) 13(1)(b) Requirement Care plans must identify all aspects of health; personal; psychological and social care needs for each person and detail the action to be taken to ensure that all these needs are met (Previous timescale of 28/02/06 not fully met). Records of all medication must be kept, including ‘when required’ items. Clear appropriate records must be kept of changes to administration instructions, including discontinuations. The protection of vulnerable adults procedures must include clear details of the action to be taken on suspicion or allegations of abuse. Staff must be made aware of this procedure. (Previous timescale of 9/9/05 and 28/02/06 not fully met). A specific reporting bad practice (whistle blowing) must be devised and staff must be made aware of this procedure.
Whincroft DS0000061077.V309362.R01.S.doc Version 5.2 Page 25 Timescale for action 08/12/06 2. OP9 13(2) 31/10/06 3. OP18 13(6) 10/11/06 4. OP19 23(4)(5) 5. OP29 19 6. OP33 24(1)(2) Action must be taken to show 10/11/06 the alterations/conservatory extension and stair lifts meet with the requirements of the appropriate authorities. The registered provider must not 27/10/06 employ a person to work in the home unless all required checks have been carried out, with records kept. The registered persons must look 31/01/07 at how their Quality Assurance system reviews and improves the quality care at Whincroft. They must supply a copy of the home’s quality of care review and improvement report to the Commission and make the report available to service users. (Previous timescales of 10/6/05, 31/10/05 and 31/03/06 not met) 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 OP3 Good Practice Recommendations All residents (including short stays) are to be informed in writing following assessment, when the home has agreed that their needs can be met. The assessment process needs to take full account of people’s communication needs; to ensure they are properly responded to. These recommendations carried forward from the last inspection: Criteria for the administration of when required and variable dose medication should be clearly defined and recorded for all service users prescribed such items. All residents should be assessed on their ability to manage their own medication. The self-administering of medication assessment should consider more fully the persons abilities to carry out this
DS0000061077.V309362.R01.S.doc Version 5.2 Page 26 2. OP9 3. OP9 Whincroft 4. OP12 5. OP21 task and result in an agreed action plan. Residents group discussion meetings should be reintroduced as an activity. The programme of available activities should be reviewed with the involvement of the residents, consideration being given to people’s known hobbies and interests. This recommendation carried forward from the last inspection: The suitability and location of the ground floor bathroom to the front of the home should be included within the registered providers long-term development plans. Whincroft DS0000061077.V309362.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Whincroft DS0000061077.V309362.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
