Inspection on 25/09/07 for Great Wheatley

This inspection was carried out on 25th September 2007.

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

The inspector 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

Great Wheatley 19/02/07

Great Wheatley 10/08/06

Great Wheatley 16/12/05

Great Wheatley 19/05/05

Great Wheatley 09/12/04

Great Wheatley 15/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Great Wheatley 3a Great Wheatley Road Rayleigh Essex SS6 7AL Lead Inspector Sara Naylor-Wild Unannounced Inspection 25th September 2007 09:30 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 Great Wheatley DS0000048207.V352114.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. Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Great Wheatley Address 3a Great Wheatley Road Rayleigh Essex SS6 7AL 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) 01268 777281 Mr Raju Ramasamy Mr Inayet Mohmed Patel Manager post vacant Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (21) of places Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Personal or nursing care to be provided to no more than 21 people. Over the age of 65 years (OP). Personal or nursing care to be provided to no more than 21 people. Over the age of 65 years with dementia (DE). Number of service users to whom personal and nursing care is to be provided shall not exceed (21) twenty one. The kitchen must be refurbished as highlighted in the home`s recent EHO visit on the 10th April 2003. This to be undertaken within six months from the date of registration. The steep slope on the patio and steps to the rear of the property present a satety hazard. A gate with access is to be fitted across both the slope area and the steps. This to be undertaken within three months from the date of registration. The front gate and the signage for the home at the entrance to the driveway require replacement. This to be undertaken within one month from the date of registration. Storage facilities for equipment must be made available. This to be undertaken within three months from the date of registration. Pipework, which is presently temporarily lagged, must be priority risk assessed and boxed in. This to be undertaken within one month from the date of registration. Individual lockable facilities within a risk-assessed strategy should be made available for service users to use in their rooms. This to be undertaken within two months from the date of registration. A plan of renewal and routine maintenance for the home should be collated and forwarded to the National Care Standards Commission. This to be undertaken within two months from the date of registration. 19th February 2007 6. 7. 8. 9. 10. Date of last inspection Brief Description of the Service: Great Wheatley is a care home, which provides services for older people in need of nursing care. Whilst most service users have long term care requirements, the home also offers short-term respite care provision when needed. The home is situated in a residential area of Rayleigh, close to all amenities and within a quarter of a mile from the A127 London/Southend. Service provision includes nine single rooms and six double bedrooms five of which have ensuite facilities. Assisted bathrooms and WCs are provided on both floors. There are four communal areas for service users and a small Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 5 terraced garden with seating. Car parking for up to four cars is provided at the front of the property. Both trained nurses and carers make up the staff team. The range of fees for accommodation and nursing care at the home is between £605.00 per week for a shared room and £635.00 for a single room. Other services such as hairdressing, chiropody and aromatherapy are available at an additional charge. Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted on 14th and 25th September 2007. During these visits Carolyn Delaney and Ray Finney accompanied the lead inspector Sara Naylor-Wild on separate dates respectively. Their records of evidence gathered are included in this report. The evidence contained in this report was gathered from discussion with service users and staff at the home, questionnaires completed by service users, relatives and professionals visiting the home, information provided to the Commission for Social Care Inspection (CSCI) including the Annual Quality Assurance Assessment, since the last report and an unannounced visit to the home on ?19th February 2007. The acting Manager assisted the inspectors at the site visits. Feedback on findings was given to her during the visit with the opportunity for discussion or clarification. The inspectors would like to thank the acting manager, the staff team, residents, relatives and visiting professionals for their help throughout the inspection process. What the service does well: What has improved since the last inspection? The acting manager had only been in post for a short time, but had begun to affect a change in the home in response to the requirements of the last inspection report and the feedback from residents and relatives. This included a review of the care planning process and the inclusion of information that gave a better person centred approach to the support staff should provide to the individual. Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 7 The acting manager stressed the partnership of working with the proprietors and this was evidenced on the day with both parties working in addressing the issues raised at the inspection. Staff reported that they felt better supported and had access to an increased level of training. They received regular supervision and felt confident in the acting managers abilities. Residents also spoke highly of the acting mangers influence in the home and also were complimentary of the staff group in general. The building is being refurbished and although not completed at the time of the inspection according to the plans will provide a beneficial additional communal space for residents. The décor of existing rooms had been refreshed and the rooms were bright, clean and tidy. 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. Great Wheatley DS0000048207.V352114.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 Great Wheatley DS0000048207.V352114.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can be confident that the home will understand their needs and have the resources to meet these prior to their moving into the home. EVIDENCE: The service was undergoing a major building project and refurbishment at the time of the inspection visit. As a result of the large-scale disruption to the home the numbers of residents living there had reduced and there had not been many new admissions. However there had been some people who had come to the home for shortterm respite stays. In one case this arrangement had been made permanent and the resident was now living at the home. The inspectors read the Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 10 documentation relating to this admission in order to gain an understanding the admission process. The documents held in the file of the resident most recently admitted included an initial contact sheet with a brief overview of the referral to the service and fuller pre-admission assessment form. The assessment covers the aspect of daily living as set out in the National Minimum Standards for Older People 2002 and is completed to a level that would enable the service to understand the areas of support the individual would require and the resources that may be needed. The form also makes reference to the input from the resident and their family and their views are represented. A resident told the inspector that they had been provided with the opportunity to visit the home if they wished prior to moving there and their family had been provided with information about the service when they had first visited the home. The resident felt they had benefited from the opportunity to stay as a respite resident before they had made the decision to stay on a permanent basis. The service was operating with a significant number of resident vacancies at the time of the inspection and the management of the admission of numbers of residents was discussed with the acting manager. She was able to indicate an awareness of the issues involved and how the needs of both the individual referred and those of the existing residents would be taken into account in progressing admissions. The service does not provide intermediate care. Great Wheatley DS0000048207.V352114.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): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that the staff understand their needs and how best to support them. EVIDENCE: The care plans for four of the residents living at the home were reviewed during the inspection visit. These contained references to all aspects of daily living that followed on from the initial assessment information. There was a sheet headed “daily routine” at the front of each set of care plans. This document describes in very positive terms residents’ day, with person centred descriptive language to identify the individuals’ preferences such as “ X likes to get up late so staff should ensure they are not disturbed whilst other residents eat breakfast”. Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 12 Overall the actual care plan is not so focused on the person centred style and tended to provide more emphasis on the individuals physical needs such as mobility, personal care and eating and although reference was made in care plan to meeting social care needs, the information in these is less detailed. This was also reflected in daily records that tended to indicate what the staff did rather than the activity undertaken and how much the plan of care was supporting the residents’ strengths. For example an entry spoke of people being fed rather than having a meal and the level of support they were given. Overall the documents do provide information about the individual resident and how staff should support them, however the reflection of good practice in recognising the individual and demonstrating respect for the diversity of the resident group could be better reflected. From discussions with the acting manager it was apparent that she understood the positive developments that could be made to the documents. All the files seen contained a range of risk assessments on file for issues such as specialist dietary needs, continence management and falls. All the files seen also contained a risk assessment for cot sides with agreements to the use of cot sides signed by relatives or residents. The risk assessments did not give an indication of the circumstances that led to the consideration of risk nor what consideration was given to other equipment or arrangements before the cot sides were decided on. There are significant associated risks to the inappropriate use of cot sides and the assessments for some residents appeared to contain information that would make the use of the cot sides contrary to safe practice. For example a resident’ s assessment stated that they did not have disturbed nights and did not move from bed, and had not fallen at night, but they had a cot side agreement. The acting manager agreed that some residents may not require this equipement and a review of the risk assessment document and the associated guidance would be provided. The management of medication was considered and evidence found of good practice in the recording and dispensing of medication. A new drugs cupboard had been created during the building works, and provides a secure place for the storage of medication and other health related equipment. The cupboard contained secure cabinets for both prescribed drugs and controlled drugs. The recording associated with the dispensing of medication in both categories was maintained to a good standard. Observations of staff dispensing drugs demonstrated an awareness of the responsibilities in this area of provision. Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 13 None of the current residents manage their own medication, although each bedroom has a locked metal cabinet that would allow for the safe storage of medication should anyone chose to do so. Some of the cabinets did not appear to be located in easily accessible positions for independent use by residents and this was pointed out to the acting manager. Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 14 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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a range of activities on offer and participate according to their preferences. EVIDENCE: The home’s activity records were examined. There is an individual record of activities for every person living in the home. These are completed daily and record what the activity is, whether the person enjoyed the activity and the name of the member of staff supporting the person. One member of staff had recorded that the person enjoyed the activity because they observed them smiling. One person’s records showed a wide range of activities had taken place in the previous weeks, including bingo, dominos, music/sing-along, card games, manicure, flash cards, quiz, chatting about the past, hand ball, toss-aring, animal cards, church service and a discussion on the news and TV ads. Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 15 Another person had someone come in to do a massage, music, hand care, facial massage, gentle exercise, talking about the past and watching television. During the inspection staff were observed playing dominos with a resident. Records examined also show that each person has an activities assessment identifying games and pastimes that the person enjoys, whether they like group activities, any family involvement, any activities that they enjoy outside the home, religious activities and personal preferences around hairdressing, beauty therapy or aromatherapy. Discussion with the manager indicated that they are making further developments in the way they support people around activities and how they are recorded. This is supported by a consultant who has developed new documentation for staff to use in working with residents in activities. The sheets identify a range of activities, the duration of the activity and asks for the residents reaction to be charted across a range of indicators such as made eye contact, nod, smile or shook their head. This tool will assist staff in identifying the individuals’ level of enjoyment even where residents are unable to give a vocal response. One person recorded in the visitors’ comments book, “My friend was happy while they were here. They liked the food and all the staff. I always got a lovely reception from the staff”. During the inspection visit the midday meal was served and staff and a visitor supported residents to eat the meal. This was carried out in a patient and timely way that did not rush the person being supported. One residents spoken with said that they enjoy the food. The home maintains a diet sheet that charts the residents’ choices and amounts consumed. Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 16 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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect their views to be listened to and acted upon. They can be confident that staff understand how to protect them from abuse. EVIDENCE: The service’s complaints policy reflects the expectation of the Care Homes Regulations 2001 and the National Minimum Standard for older people. There is a complaint log maintained by the service and this was viewed at the inspection. There had not been any significant complaints logged since the last inspection. The need to ensure that all levels of complaints and concerns are recorded as part of the service’s quality assurance was discussed with the acting manager. The Commission is not aware of any complaints made since the previous inspection. The service has a safeguarding policy and procedure that adheres to local guidance in relation to the action taken in reporting abuse. Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 17 All the staff receive training in Safeguarding adults in the Protection of Vulnerable adults sessions. Staff spoken with were aware of their responsibilities in this area and understood the home’s whistle blowing policy. Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 18 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): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from premises that meet their needs. EVIDENCE: As already stated in this report the service was undergoing a full-scale refurbishment and building programme at the time of the inspection visit. The works were scheduled to complete at the end of September. The building works were mainly focused on the front of the home in converting a number of smaller rooms into a large communal lounge/diner and office spaces on the ground floor. Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 19 The area in which the work was being carried out was secured from residents as much as possible in order to protect their health and safety. Issues previously found in the inspection visit of where the fire warning and detection systems were compromised by the building works had been addressed and no such risk existed at this visit. As well as the building works the proprietors had taken the opportunity to carry out some refurbishment of existing bedrooms including the residents rooms. These were freshly decorated and new curtains, flooring and bedding provided. These rooms appeared clean, tidy and airy. The acting manager reported that at the point of completion the communal corridors and lounges would have new flooring and décor to match the rest of the home. There were no odours detected in the home and the premises appeared clean and tidy. Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 20 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): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that there are sufficient numbers of staff with appropriate skills to support their needs. EVIDENCE: Rotas examined record that there was a mix of qualified nursing staff and unqualified care staff on every shift. Observations on day of the inspection visit confirm that the number of staff on duty were meeting the needs of people living in the home. There was a ‘List of Duties’ for both day and night staff giving staff clear guidelines on their responsibilities and tasks that need to be carried out. A sample of 4 staff files was examined at the inspection visit. At the front of the files was a checklist of all the documents required by Regulation. Although the checklists were not all completed, examination of the files confirmed that all the required documentation is in place. Staff files examined all contains recent photographs of the member of staff, proof of identity, two written references and a health declaration. Evidence was seen that enhanced Criminal Record Bureau (CRB) checks are carried out before the member of staff commences employment. Files relating to Registered Nurses contain Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 21 proof of their registration with the Nursing and Midwifery Council and their Personal Identification Numbers. The files were well organised. Staff training records were also examined. Planned training is recorded on a staff training matrix and covers Protection of Vulnerable Adults (POVA) training, Dementia Care, Challenging Behaviour, Infection Control, Fire Safety, Food Hygiene, continence Promotion, health & Safety, Manual Handling and Medication Administration. There is a timetable of planned training in place with dates identified up to July 2008. Staff who need to attend or update any particular training have been identified and this is documented with the matrix. In addition each member of staff has an individual training record of training courses they have completed. Individual training records confirm that the range of in-house training identified in the staff training records is carried out. A discussion with the manager confirmed that, although training is carried out in-house, external trainers come in to deliver the training. Individual staff training records contained preparation sheets that staff complete before training to identify what they expect and require from the training. A range of completed worksheets are in place that demonstrate what each person has learned in the training session. Staff files examined contains a checklist of the issues covered during staff induction. Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 22 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): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a committed management team, who listen to their views and respond to improve the service. EVIDENCE: The acting manager has previously worked at the home in a Senior Care capacity. She knows the service, the residents and the staff group and from discussions with the inspectors had good insight into the develoopments required to comply with the services outstanding requirements of the Care Homes Regulations 2001. Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 23 The inspectors were impressed with the acting manager’s commitment to improving the service and the core understanding she has of good practice in promoting the rights of individual residents. The proprietors were encouraged to support the acting manager to further develop her skills and progress her application for registration as manager of the service. Two members of staff spoken with were positive about how the home is now managed. One said, “Things have greatly improved recently since the acting manager took over. Staff training has improved and things are looking up”. A visitor who spoke with the inspector stated that “things had got a lot better since the acting manager had taken over and they no longer had concerns about the way the home was running, she makes herself available when ever we need her, we even have her mobile phone number to call 24 hours a day”. Prior to this inspection visit, as requested, the home sent an Annual Quality Assurance Assessment to us at the Commission. The manager had completed the AQAA, although in some sections the information provided was brief. In view of the fact that the AQAA has only recently been introduced, some additional guidance may be needed with the new methodology. However, other documentation examined was seen to be good overall and with guidance the quantity and quality of information recorded on the AQAA could be improved. Quality assurance systems are operated in the home and a comprehensive report is held at the premises. However the accessibility of this for residents and their supporters should be considered to ensure they understand how their comments are influencing the way the service is developing. There are now regular meetings with stakeholders such as staff, relatives and residents, and the minutes of these are posted in the front of the home. Relatives had commented on how much improved the communication is with them and identified this as part of that. Staff records examined show that a programme of regular supervisions is now in place. The staff supervision planner showed that staff are having supervisions two-monthly. All staff have had between two and four recorded supervisions and there were dates of further planned supervisions. Certificates relating to the annual maintenance of equipment to comply with health and safety regulations were seen at the inspection visit. These included maintenance checks on moving and handling equipment, fire safety equipment and electrical supply and equipment. All documents were in date and satisfactory. Great Wheatley DS0000048207.V352114.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 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 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 3 3 X 3 3 X 3 Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 25 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. Refer to Standard OP31 OP7 Good Practice Recommendations A suitably qualified person must be employed to manage the home. Care plans should be developed to ensure they are person centred and reflect the diversity of residents. This ensures that staff understand how to provide support in a way that benefits the individual. A minimum of 50 of care staff should have undertaken NVQ training in care. This level of basic skills supports the staff in meeting the residents’ needs. The outcomes of the quality assurance information gathering exercises should be translated into more accessible format. This will ensure that stakeholders understand how their feedback is acted upon. 3. 4. OP28 OP33 Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Great Wheatley DS0000048207.V352114.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!