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Inspection on 15/11/05 for The Wells Nursing & Residential Home

Also see our care home review for The Wells Nursing & Residential Home for more information

This inspection was carried out on 15th November 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Wells Nursing Home offers a good level of professional care. The home is well managed and has a very dedicated staff team. Care plans have improved and record relevant information to demonstrate the good level of care input. The catering is of a good standard and there is choice and attention to dietary likes, dislikes and special requirements.The home has good links with the community health care services and has established a pharmacy service that is working well for the home. Service users were satisfied with the care and service they receive at the home. Relatives and professionals also offered positive feedback about the care given at the home.

What has improved since the last inspection?

Attention had been given to the storage of chemicals in line with COSSH guidance. The domestic staff had given the carpets a deep clean before this inspection and the whole home looked fresh and clean. Attention to the health and safety aspects required in the last inspection had been attended to. Waste bins were easy action, an infection control measure that was required at the last inspection.

What the care home could do better:

Care plans do not all demonstrate the service users involvement in the planning process, which allows service users who are able to positively influence the care and service they receive. Carpets were due to be replaced in corridors; this will no doubt enhance the appearance of the environment. The feedback from relatives included comment on the stained condition of corridor carpets and the decorative and maintenance aspects affecting the presentation of the premises. Bed rails need to be regularly monitored for fitting in the correct position and be secure to reduce the risk of entrapment and injury. The Manager was advised to access the information issued by the Medical Devices Agency with regard to bed rails. Medications management was satisfactory with the exception of hand transcribed entries; these had not all been signed or countersigned to confirm accuracy of the entry. The medications fridge temperature was being recorded. However the temperature needs to be monitored as a minimum and maximum reading. Consideration may need to be made to the position of the fridge as the room felt quite warm and the fridge temperature had been recorded at 9 degrees Celsius, the recommended safe range is 2 to 8 degrees Celsius.

CARE HOMES FOR OLDER PEOPLE The Wells Nursing & Residential Home Henton Wells Somerset BA5 1PD Lead Inspector Barbara Ludlow Announced Inspection 15th November 2005 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 The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 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. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Wells Nursing & Residential Home Address Henton Wells Somerset BA5 1PD 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) 01749 673865 01749 676878 The Wells Nursing and Residential Home Mrs Rachel Mary Collins Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Up to ten places for personal care. Elderly persons of either sex, not less than 60 years, who require general nursing care. Four persons of either sex, in the age range of 40-59 years, who require nursing care by reason of physical disablement. 25th May 2005 Date of last inspection Brief Description of the Service: The Wells is a Care Home with Nursing. The service provides support for 39 service users in both Nursing and Personal Care only categories. The Wells Nursing Home is situated on the main road through the village of Henton near the City of Wells.The accommodation is on two floors with a passenger lift to the first floor where 25 of the 39 bedrooms are located. All the bedrooms are single occupancy, some with en-suite facilities, which includes a wash hand basin and toilet. On the ground floor there is a lounge, a dining area and a conservatory. There is a garden at the rear of the building with an open outlook and views and a more cottage style garden to the side of the building. The rear garden is accessible from the conservatory and car park with one boundary now fenced for safety. Laundry processing and all catering are managed ‘ in-house’. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by B Ludlow and J Button for CSCI. The Manager was on duty throughout the inspection day. Requirements made at the last inspection had been addressed. Pre-inspection information was submitted and feedback cards were received from 24 service users, 26 relatives/friends and 3 visiting community health professionals. The analysis of their comments is included in the text of the report. A tour of the premises was made and service users were seen and spoken with both in the communal areas of the home and in their own rooms. There were 34 service users in total residence with 25 receiving nursing care. All service users were seen and the inspectors spoke with twenty of the service users. The home was warm and clean and very positive feedback was heard from service users and staff. Activities during the day and the serving of lunch were observed. The homes administrator was also on duty and available to locate records as required for inspection purposes. Records sampled included care plans, staff files, maintenance, servicing records and medication administration. Eight staff were seen and spoken with; all were helpful during the inspection process. Positive feedback was heard from the staff team. Inspection feedback was given to the Manager at the conclusion of the inspection. Immediate requirements were made for bed rails that were not adjusted to fit securely and for obtaining CRB checks for staff employed from overseas. Confirmation was received from the proprietor, Mrs Bila to advise CSCI that these areas had been promptly addressed after the inspection. What the service does well: The Wells Nursing Home offers a good level of professional care. The home is well managed and has a very dedicated staff team. Care plans have improved and record relevant information to demonstrate the good level of care input. The catering is of a good standard and there is choice and attention to dietary likes, dislikes and special requirements. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 Page 6 The home has good links with the community health care services and has established a pharmacy service that is working well for the home. Service users were satisfied with the care and service they receive at the home. Relatives and professionals also offered positive feedback about the care given at the home. What has improved since the last inspection? What they could do better: Care plans do not all demonstrate the service users involvement in the planning process, which allows service users who are able to positively influence the care and service they receive. Carpets were due to be replaced in corridors; this will no doubt enhance the appearance of the environment. The feedback from relatives included comment on the stained condition of corridor carpets and the decorative and maintenance aspects affecting the presentation of the premises. Bed rails need to be regularly monitored for fitting in the correct position and be secure to reduce the risk of entrapment and injury. The Manager was advised to access the information issued by the Medical Devices Agency with regard to bed rails. Medications management was satisfactory with the exception of hand transcribed entries; these had not all been signed or countersigned to confirm accuracy of the entry. The medications fridge temperature was being recorded. However the temperature needs to be monitored as a minimum and maximum reading. Consideration may need to be made to the position of the fridge as the room felt quite warm and the fridge temperature had been recorded at 9 degrees Celsius, the recommended safe range is 2 to 8 degrees Celsius. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 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 Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 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 The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 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): 1,2,3,4,5, NMS 6 does not apply. The home has detailed information available for service users and their families and carers choosing a care home place. The home’s Manager undertakes pre admission assessments to ensure prospective service users needs can be met at the home. Visits are welcomed. EVIDENCE: The home has a Statement of Purpose and Service User Guide. Service users have access to clear information about the home. This information in a pack format was sampled and was clear, the homes brochure, a welcome letter, A to Z of services and the Philosophy of Care is included along with the homes complaints procedure. The complaints procedure requires updating from NCSC to CSCI and a time scale of a maximum of 28 days should be included. Two visitors called at the home to take a look around during the inspection, they had no appointment but were shown around the home by the Registered Nurse. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 Page 10 Pre-admission assessments are made by the home’s manager; care plans sampled at this inspection included evidence of the initial assessment. The terms and conditions of residency include a trial period of one month, with fees paid monthly in advance. The current fees rates were set in September and range between £462 and £504 for residential care and £574 to £616 for nursing care. The rates vary dependent upon the room occupied, the higher charges being made for en suite facilities. The home has an administrator to deal with all accounts. Financial accounts were sampled these demonstrated clearly the charges made. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 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): 7,8,9,10,11 Care plans sampled demonstrated a good level of attention to health care needs. Service users confirmed that they are treated with respect. EVIDENCE: Care plans were in place for all service users, including those on respite care stays. The care plans contained a good level of care information. Visits by health and allied health care professionals such as the chiropodist were recorded and health care input was satisfactory. Attention to the care of assessed pressure sore risk and the use of pressure relieving equipment was detailed. No one was reported as having a pressure sore at this inspection. Nutritional requirements and risk had been assessed and weight was monitored and recorded. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 Page 12 Not all demonstrated a person centred approach to care planning this should continue to be worked towards. The home is using a Bristol based pharmacy service. Specific conditions where blood tests are required are monitored by the pharmacy service and blood tests are prompted. This service is closely linked to the Wells Primary Health Care Trust (PCT) provision. Positive written feedback was received from 2 visiting GP’s and one District Nurse. Written feedback from relatives indicated that they felt their relative could be assisted more promptly when requesting assistance to the toilet. Concern was also raised about the use and frequency of changing incontinence pads. Two of the twenty respondents said that they were not always kept informed of important matters affecting their relative or friend. All relatives indicated that they are satisfied with the care their relative receives; additional comments included ‘sometimes’, ‘not always’ and ‘fairly’. Medication management was examined; MAR charts were satisfactory with the exception of signatures to verify hand transcribed entries. The stocks were sampled and date expired syringe driver giving sets were seen, these need to be replaced. The maximum room temperature where medications are stored should be no more than 25 degrees Celsius. The medications fridge was reading 9 degrees Celsius; the optimum range is 2 to 8 degrees Celsius. The medications fridge daily temperature record should be monitored as minimum/maximum temperature. It is recommended that these temperatures be monitored and be kept within the recommended ranges. The homely remedies policy and the self-medication policy required dating and signing. Service users confirmed that they are treated kindly and with respect. Staff were observed to knock on bedroom doors and wait before entering. The home has agreed to meet the Gold Standards Framework for end of life care and has input from the local PCT lead advisor with records for care held by the G.P for continuity of care and to ensure that care given is what has been agreed with the service user and their Doctor and is in line with their wishes. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The inspector’s observed good practice and visitors spoken with confirmed that they are made welcome. The home’s ethos supports choice, independence and values the individual. The catering was confirmed by service users to be good. EVIDENCE: Service users were spoken with and asked for their views on how they spend their time and of the food offered. Positive comments were heard about the activities offered. Activities are led by the activities coordinator. Painting and a craftwork session were seen to be enjoyed by a small group in the conservatory, at this inspection. Service users were using their skills to prepare small items for sale for Christmas. Flower arranging is another popular activity. The inspector was informed that library books can be accessed from a trolley library and the hairdresser visits twice a week. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 Page 14 Visitors were seen they said they are made welcome and are offered refreshments. Service users also commented on the welcome received by their families and friends, one relative had participated in an activity held at the home. All relatives responding in writing confirmed that they could see their relative in private if they wish. Twenty-four of the twenty-six respondents said that felt welcomed by staff when visiting the home. The kitchen was seen and the home offers home cooked food. All records were up to date and kitchen was clean and well organised. The menu was nicely presented at lunchtime and was: pork and apricot cream, broccoli, carrots and potatoes. Salad with prawns was served as an alternative main menu and the dessert was black forest trifle. Yogurts and fresh fruit are available as alternative desserts. The teatime menu is soup or fruit juice followed by a cold or hot option. The menu is rotated over a 5 week cycle. The cook has likes and dislikes and special dietary needs recorded, there is also a birthday list so that celebratory cakes can be made and presented. 18 of 21 respondents said that they liked the food, 3 said sometimes, comment included excellent to mediocre. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 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): 16,17,18 The home has the complaints policy, which was on display at the home. A copy of the complaints policy is in the welcome pack. Recruitment policies and procedures are in place to protect service users from abuse. However CRB checks for overseas recruited staff had not been taken up, this was addressed after this inspection day. The home has a whistle blowing policy. EVIDENCE: There have been two complaints made to the home since the last inspection. One was substantiated and has been closed; one made recently is being investigated. The complaints procedure was displayed at the home and was seen in the welcome pack sampled. The document did not have a timescale for response; this needs to be set within a maximum of 28 days. The document needs to be updated with CSCI replacing NCSC. (The CSCI address remains the same). All service users responding in writing said that they felt safe at the home, all were treated well by staff and 15 of 18 respondents said that they knew who to speak with if they were unhappy with their care. Relative and carer responses indicated that 17 of the 24 respondents were aware of the complaints procedure and 9 of the 26 respondents said they had made a complaint. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 Page 16 CRB checks for overseas recruited staff had not been taken up. These staff had country of origin police checks but CSCI regulation also requires a UK, Criminal Records Bureau check to be undertaken for overseas recruited staff. It was agreed at the inspection that these would be undertaken with a POVA First check, as soon as possible. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 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): The home was clean, tidy and homely; there is a need for ongoing maintenance and general upkeep of this home. The outdoor garden areas are very attractive but require attention to keep them tidy and accessible. EVIDENCE: This home was registered pre 2002, and as such has not had to comply with any environmental changes. The home has been maintained during this time and some adjustable beds have been purchased. The communal areas were clean and tidy. There is a nurse call system throughout the home. The Manager confirmed that the call bell system is periodically checked. One relative reported on the written feedback to CSCI, finding the call bell detached from its socket on more than one occasion, the Manager was alerted to these occurrences. Staff must be vigilant and ensure all service users can easily access help if required. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 Page 18 Bathrooms are assisted; one bathroom with an out of use toilet remains shabby. The floor covering is worn and the plaster on the walls was damaged. The blind on the window was broken and was hanging down. The bath is a short length one and access for the use of the mobile hoist is restrictive by design. This bathroom requires attention to the floor covering, the blind and the decoration. Longer term consideration should be given to the modernising /refurbishment of this and one other bathroom with the same layout. Eight of the 39 single bedrooms are en suite, all bedrooms are comfortable and can be personalised by the service users and made homely. 4 bedrooms have been redecorated since the last inspection, 11 remain to be re-decorated. One window restrictor was seen to have been taken off on a first floor window; this was brought to the Managers attention for replacement. The corridor carpets had been deep cleaned before the inspection and looked clean. The inspectors were informed that new carpets are due to be fitted. One armchair in the lounge was seen to be dirty. Comment from both relatives and service users indicated that access to the garden could be improved to make it easier for service users to use. One bedroom window had a garden shrub growing close by this could reduce the daylight in the room and should be kept tidy to prevent this occurring. The garden pathway leading from the ground floor corridor fire exit looked green and should be maintained and monitored for cleaning as it could become slippery. Infection control was of a good standard. Odour detected in two areas was discussed with the manager at the inspection. Service users spoken with and asked were satisfied with their rooms. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 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 The home has a dedicated core staff team. There were sufficient numbers of staff on duty. Domestic vacancies have been addressed. EVIDENCE: The home had sufficient care and nursing staff on duty. The feedback from 5 of the 22 relatives and friends indicated that they do not always feel there is enough staff on duty when they visit. 23 relatives felt welcomed when they visit the home. One service user spoken with commented that her family enjoyed visiting and were offered ‘a cup of tea’. The service users indicated that all felt safe at the home and all staff treat them well and respect their privacy. The home does not have dedicated maintenance staff but uses a local contractor for maintenance work and gardening. Staff confirmed that recruitment to fill domestic vacancies had been made with a positive impact on the cleanliness of the environment. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 Page 20 Staff recruitment was examined and found that the overseas staff had only their country of origin police checks. CRB checks with a POVA First check is required in line with Regulation 19 (CHR, 2003) The administrator agreed to action this misunderstanding without delay. Staff confirmed that they received induction when coming to work at the home, which included manual handling training. Training and development is encouraged. Staff supervision has not yet been fully implemented. This is recommended. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 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): 31,32,33,34,35,37,38 The home has an experienced Registered Nurse Manager and there is administrative support. The home has good occupancy rates. Service users spoke positively about the care and service they receive at The Wells. Records are well managed and are stored securely. EVIDENCE: The home has an experienced Registered Nurse Manager. The service users spoke highly of the Manager, reflecting on her approachability and kindness. There is administrative support to assist the Manager with contracting and staff recruitment etc. Service users contracts and personal finances were seen at this inspection and were clear, appropriately stored and with restricted access for security. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 Page 22 The home has good occupancy levels and the Manager and administrator both confirmed that the proprietor is planning to invest in the home. Replacement corridor carpets had been ordered. Staff are supervised in their daily work and regular staff meeting are held for the three groups of staff care staff, registered nurses and the domestic team, however formal supervision has not yet been fully established and will be monitored at the next inspection. Policies and procedures are in place for most aspects of running the home. The homely remedies policy and the self-medication policy required dating and signing. Maintenance and servicing records examined included: Weekly fire alarm tests are carried out. The fire alarm system was serviced on 6.10.05; Fire extinguishers were checked on 8.7.05. In house emergency lighting checks are carried out at 3 monthly intervals. The last fire training session was held on 24.10.05 and the last fire drill was carried out on 28.10.05. Legionella analysis was undertaken on the water supply in February 2005 and was clear. The passenger is serviced three monthly, last 8.11.05. The five yearly hard wiring certificate was dated 6.03. The patient weigh scales had been calibrated. Hoists had been serviced in line with LOLER on 12.11.05. The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 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 1 3 3 1 3 3 3 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 3 3 3 2 3 3 1 The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 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. 1 Standard OP9 Regulation 13(2) Requirement Timescale for action 22/12/05 2 OP29 19(4)(b) (i) 3 OP38 13(4)(c) 4 OP19 23(2)(b) MAR charts must be signed to verify hand transcribed entries. Stock nursing equipment for example, syringe driver giving sets such be checked for date expiry and replaced as required. The medications fridge daily temperature record should be monitored as minimum / maximum temperature and kept in the safe range of 2 to 8 degrees Celsius. The homely remedies policy and the self-medication policy require dating and signing. Criminal Records Bureau check 22/11/05 to be undertaken for overseas recruited staff. It was agreed at the inspection that these would be undertaken with a POVA First check, as soon as possible. An immediate requirement was made. Bed rails must be compatible 22/11/05 with the bed and service user and be safely fitted. An immediate requirement was made. The ground floor bathroom, 22/01/06 DS0000003304.V255319.R01.S.doc Version 5.0 The Wells Nursing & Residential Home Page 25 which is poor by design, is also in a poor state of repair and requires attention to the blind, the floor covering and the decoration. 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 OP16 Good Practice Recommendations The complaints procedure should be updated from reading NCSC to reading CSCI. A time scale of a maximum of 28 days or less for the commencement of a complaint investigation should be included in the policy and procedure. Effort should be made to have the process of staff supervision more formally integrated into the working management practice of the home. The proprietor should give consideration to the general maintenance and upgrading of the premises. Path surfaces should be maintained for safe use and where identified as fire escape routes. The garden should be kept tidy especially where shrubs are close to bedroom windows. 2 3 OP36 OP19 The Wells Nursing & Residential Home DS0000003304.V255319.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. 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