CARE HOME ADULTS 18-65
The Wimbledon 58 Selsea Avenue Herne Bay Kent CT6 8SD Lead Inspector
Christine Grafton Unannounced Inspection 13th July 2007 09:30 The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Wimbledon Address 58 Selsea Avenue Herne Bay Kent CT6 8SD 01227 370909 01227 370909 wimbledonhouse@btconnect.com allaboutcare@btconnect.com All About Care Ltd 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) Mrs Michelle Abbott Care Home 34 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (17), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (17) The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st August 2006 Brief Description of the Service: The Wimbledon is a large, detached, two-storey older property, which has been adapted for its present use. When full, there is provision for three of the bedrooms to be shared by two people each and currently two of those rooms are occupied singly. All of the other bedrooms are for single occupancy. Access to the first floor is by stairs. The home was refurbished in 2007 and bedroom accommodation now includes eight new ground floor single bedrooms with ensuite facilities, including two that have been adapted for use by people with disabilities. The home is situated in a quiet residential area. The nearest shops are within normal walking distance. The staff team consists of a manager, a deputy manager and a team of carers who work a rota that includes three staff on ‘waking’ duty at night. There are additional staff employed to cover catering and domestic tasks. The current fees for the service at the time of the visit range from £379.07 per week to £425.00 per week. The e-mail address of the home is wimbledonhouse@btconnect.com. The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report takes account of information received since the last inspection, including a visit to the home. An unannounced visit took place on 13th July 2007 between 09.30 hours and 15.50 hours. The visit included talking to the manager, staff and residents, looking at some records and looking round the communal areas of the home. In addition to this, five bedrooms were seen with the residents’ permission. At the time of the visit there were twenty-eight residents living at the home. Surveys have been sent to a sample number of residents and care managers. However due to them being sent out at short notice on this occasion, responses have not yet been received at the time of writing this report. The findings of this inspection indicate that the people living in this home enjoy a good quality of life. What the service does well:
Residents spoken to like living at the home and expressed their satisfaction with the support they receive from staff. Residents have opportunities to take part in a variety of activities. They have activities arranged for them at the home and can attend sessions at the day centre, located in the ‘sister home,’ which is also in Herne Bay. They go out into the community a lot. Some residents go out on their own, some go out with staff support on a one to one basis, or small groups go out with staff in the home’s people carrier. Residents are encouraged to maintain their independence. They are supported to make decisions about their lives and have a say about what goes on in the home. The environment is homely and comfortable and there is a warm, welcoming, relaxed atmosphere. Residents get the sort of healthcare support that they need and are fully involved in the planning of their care. Staff receive the right sort of training to enable them to do their jobs properly and understand residents’ needs. Good health and safety monitoring arrangements are in place to protect residents, staff and visitors to the home.
The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better:
Residents said that the provider visits the home regularly and they know they can speak to him if they want. The provider now needs to complete the home’s quality monitoring processes by carrying out the formal monthly visits and reports that are required, to ensure that the service delivery is meeting all relevant legislation. This is important to make sure that the home is being managed effectively and any issues affecting the outcomes for residents can be picked up and acted upon promptly. This has been identified as an area for improvement at the last two inspections, but as significant efforts have been made since the last inspection to strengthen the home’s quality monitoring processes, the requirement has not been carried forward. This is because the manager indicated that the
The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 7 provider had arranged for several monitoring checks to be done, but had misunderstood how to do the monthly reports. She said she felt sure these would be completed in future. The medication cupboard is old and a recommendation has been made to review the medication storage to make sure there is sufficient space for the amount of drugs that need to be kept at the home and for internal and external medications to be kept separately, for safety. The home’s statement of purpose and service users’ guide need reviewing and updating to take account of recent changes. This is important to ensure that people have access to accurate information about the home. The manager indicated that this would be addressed. The manager has already identified an improvement needed to provide training for staff to develop their confidence when dealing with behaviours they find challenging. This has already been arranged to make sure that staff have the right skills to protect the rights and best interests of residents. The manager also has plans to continue her personal development by attending a counselling skills course. The skills she develops from this will also benefit 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. The summary of this inspection report can be made available in other formats on request. The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People moving into the home can expect to be provided with the information they need to make an informed decision about its suitability. However, some of the current written information is in need of review. They can be confident that their needs will be properly assessed and they will be supported to achieve their aspirations. EVIDENCE: There is a service users’ guide that provides a picture of what to expect at the home. However, there are some elements that are now out of date and a review is necessary. The addition of a summary of service users’ views of the home would provide people with first hand information about the quality of some of the services referred to in the guide. The statement of purpose is also overdue for review. The manager agreed to make sure that both these documents are updated. There is a separate informative brochure with more up to date information about the home that the manager said she shows prospective residents to inform the decision making process.
The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 10 Prospective residents’ needs are thoroughly assessed before admission. The manager stated that usually people are referred via care managers and the social services Care Programme Approach (CPA) process. The manager ensures that copies of care management assessments and risk assessments are obtained first and then the home carries out its own assessment. The manager meets with each prospective resident to assess their needs, using an assessment tool that covers such things as: accommodation requirements, personal support needs, educational and occupational needs, important relationships, general healthcare, physical care needs and mobility, mental health care, the individual’s aspirations for the future and a risk assessment. Evidence was seen that an assessment had looked at the aids and equipment needed and ensured that the relevant things were in place at the home. From discussion with the manager it was also clear that she considers whether the staff have the skills to meet identified needs and if not, then either the referral is not progressed any further, or arrangements are made for the staff to receive the relevant training. A resident spoke positively about their admission to the home, saying that they had been given all the information they needed, that their bedroom was suitable and that staff understand their needs. The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their individual plan of care will ensure that their needs and aspirations are met in a consistent way. They can feel assured that they will be supported to make decisions about their lives and to take responsible risks. EVIDENCE: Each resident has an individual plan of care that has been discussed and agreed with them. Care plans contain detailed information about the support residents need from staff and show how changing needs are met. Each identified need has a clear plan of action for staff to follow, which is regularly reviewed and updated. The manager has improved the care plan format since the last inspection and where there are complex needs the action plans are more detailed. This ensures that residents’ needs are met in a consistent way. This was supported in separate discussions with a resident and their key
The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 12 worker. What each person said matched what was described in the written care plan. The resident confirmed that they receive the assistance they need from staff. Discussions with residents and staff indicated that residents are supported to make decisions about their daily lives and are encouraged to participate in the home’s decision-making processes. Staff support residents individually to make choices as part of their key worker responsibilities and on a general dayto-day basis, all staff are ready to listen to residents to help them make decisions. The home has accessed an independent advocacy service on a resident’s behalf. Residents are able to influence decisions about the day to day running of the home within the regular monthly residents’ meetings. Issues discussed at these meetings include menus, trips out and activities in general. Residents are supported to manage their own finances. Good records are kept of residents’ monies and both the resident and staff member sign each transaction. Risk assessments are completed for each individual risk identified within the care planning process. These provide guidance for staff on how to minimise risk, with clear strategies agreed with the resident and their care manager. Risk assessments are regularly reviewed and updated as changes occur. The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be confident that they will be enabled to take part in a wide range of meaningful activities to suit their individual needs. They will have opportunities for personal development, be able to maintain their independence, be a part of the local community and enjoy good food. EVIDENCE: Residents can choose from a range of occupational opportunities available to them both within the home and in the wider community. They can go to The Heron Day Centre at the sister home, The Hailey, if they choose, where they can take part in cooking and gardening groups and join weekly trips out to places of interest. At the time of this visit, a small group were going to the Kent County Show. The activities co-ordinator works full time between the two homes and does activity sessions at The Wimbledon, plus care staff have a
The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 14 weekly activity rota that they follow. This includes board games, exercise groups, bingo, crafts, music and singing, table tennis, pool, and lots of individual trips out on a one to one basis. Some residents attend independent living skills classes organised at the local mental health centre. An entertainer is due to visit the home in August. Residents spoke enthusiastically about their various local outings and minibus trips further afield. Staff spoke positively about being given allocated time to do activities with residents, recognising the importance of this to ensure residents have a good quality of life. Many residents go out independently, but those that need staff support are enabled to go out regularly. Residents are supported to maintain relationships that are important to them. Residents confirmed they see their visitors at the home and go out to see relatives and friends. Two residents spoke about an important celebration organised for them by the home, to which their families and friends were invited. The manager stated that residents’ religious needs are supported and two residents sometimes attend church services. Personal relationships are also supported. The weekly menu plan is displayed in the dining room. Residents confirmed they are involved in the menu planning and that they can choose from a range of alternatives if they do not like the set menu. Residents said they enjoy their meals and always have enough to eat. They are offered snacks in between the three main meals, including sandwiches at suppertime. Residents can choose from a variety of hot and cold drinks that are available at all times. The lunchtime meal was well presented. The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from the good healthcare support provided at this home and they can be assured that their physical and emotional healthcare needs will be met. Residents are protected by the home’s procedures and practices for dealing with medications. EVIDENCE: The manager makes sure that carers know each resident’s preferences about their personal care needs, especially when providing intimate personal care. This is fully recorded in the individual care plans and discussed at shift handovers. A resident said that staff always listen to how they want to be assisted and confirmed that staff take care to ensure their dignity is respected. Staff were observed providing sensitive support to residents. Residents with complex needs have their needs assessed by professionals, such as occupational therapists and community nurses, for any aids and
The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 16 equipment they need to maintain their independence. The home then ensures that these are provided. The home ensures that residents have access to healthcare professionals, such as doctors and consultants and where necessary, they are supported to attend appointments. Care plans contained details of contacts with other healthcare services such as chiropodists and opticians. Care staff spoken to demonstrated a good understanding of some complex health needs. Specialist health care needs associated with such medical conditions as diabetes are well documented in the care plans, with detailed guidance for detecting possible complications at an early stage and what action to take. Relapse indicators are well documented in the care plans, setting out the individual behaviours displayed that would indicate if the person is having a mental health relapse. The home has good links with the local mental health team and professionals from out of area and seeks prompt advice where necessary. Currently there are no residents who manage their own medications, but the manager confirmed that residents have been supported to self-medicate where their risk assessment indicates it would be appropriate. The home uses a monitored dosage medication system. Two staff always administer the medications together and medication administration records are appropriately kept. Staff are diligent in reporting if a resident refuses their medication and the manager follows this up with the doctor and community psychiatric nurse. The manager does medication competency assessments with all care staff that administer the medications. A number of staff have attended external medication training. The medication cupboard is old and storage could be improved to provide more space so that internal and external medications can be kept separately, for safety. A recommendation has been made to review the medication storage with reference to the Royal Pharmaceutical Society guidance. Parts of the medication cupboard were sticky and in need of cleaning to ensure safe hygiene. The manager said that this would be addressed. The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their views are listened to, taken seriously and acted upon and that they will be safeguarded from abuse. EVIDENCE: Residents said that they can talk to any of the staff if they have a concern. They knew they could go to the manager and said that the owner visits regularly and talks to them to see if they are satisfied with services provided at the home. Residents also spoke about their residents’ meetings as a forum to air their views and raise any matters that might be troubling them. Two residents spoken to were appreciative of the regular one to one times spent with them by their key workers. Complaints procedure notices are prominently displayed. Carers spoken to demonstrated a good understanding of what constitutes good care practice and what to do if alerted to an instance that might indicate a need to make a ‘safeguarding adults’ referral. Staff receive induction and on-going training that covers how to deal with any allegations of abuse. The manager demonstrated a good understanding of her responsibilities under the local ‘safeguarding adults’ protocols and procedures. The manager has highlighted a need for staff to develop their understanding of how to manage challenging behaviours and training has been arranged.
The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Recent investment has significantly improved the appearance of this home, creating a comfortable and safe environment that suits residents’ individual and collective needs. EVIDENCE: The renovation and refurbishment programme has now been completed. The exterior has been painted, with new guttering and some replacement windows, and the garden area landscaped. Work completed since the last inspection includes the creation of a new well-equipped shower room, the creation of an enclosed cupboard for the loft ladder, a new manager’s office and separate carers office. The new wing includes eight single bedrooms with ensuite facilities, two of which have been specially adapted for use by disabled people. Residents occupying some of these rooms expressed their complete satisfaction with the
The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 19 new accommodation. Several residents occupying bedrooms in the older part of the building said they like their rooms and that they have everything they need in them. The designated room for smoking has patio doors that lead onto a decked area with wooden tables, benches and umbrellas. Residents were seen making good use of this facility and of the other garden areas. The home is clean, comfortably furnished and maintained to a good standard. There are adequate numbers of toilets and bathrooms, with plentiful hand washing facilities and well-stocked supplies of liquid soap and paper towels. This reduces the risk of cross infection and protects residents and staff. The laundry room is a well-equipped, clean and spacious. Soiled articles are put into water-soluble bags and then straight into the washing machine. The home does not have a sluice facility. One resident uses a commode at night, which is emptied in a nearby bathroom and the commode pan cleaned in the laundry room sink. The manager is aware that it might be necessary to review this and provide a sluice facility if residents’ needs change. The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from the numbers and skill range of staff who work positively with them to improve their quality of life. They are protected by the home’s recruitment procedures and the ongoing staff training. EVIDENCE: The home was well staffed at the time of the visit. Staff demonstrated good attitudes towards residents. Discussions with residents indicated their views that staff are good listeners and understand their needs. Staff are encouraged and supported to achieve their National Vocational Qualification (NVQ) in care level 2 and receive training to ensure they have the specialist skills needed in areas such: as mental health, diabetes and equality and diversity. A staff member described their recruitment and induction process. They confirmed an application form was completed; they attended an interview, had their references taken up and a police check done. Their induction had consisted of being shown round the home, having the fire procedure explained, going through health and safety procedures and working through an
The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 21 induction book that the deputy manager signs off. They confirmed they have been booked to attend mandatory training courses and they receive “proper one to one’s”. The staff member went on to say that this is a good organisation to work for, where things are done properly and staff have proper handovers in the office. Two staff files were checked and seen to contain basic information, including a photograph, job description, induction and training records. Discussion with the manager indicated that staff recruitment documentation is kept at the organisation’s office in the sister home, where an administrator sees through the process. The manager confirmed that she sees application forms, does the interviews and writes an interview record. However, she does not always see the references and could not confirm whether a new staff member’s criminal record bureau check (CRB) had been done, or if the protection of vulnerable adults register (POVA) first check had been completed before the person started working at the home. Both the manager and the staff member confirmed that new staff shadow an experienced staff member when they first start and they are properly supervised. However, it was discussed with the manager that as a measure of good practice she should ensure for herself that all the required checks have been completed, so as to fulfil her responsibilities to safeguard residents. One way of demonstrating this is to add a checklist to the staff files reflecting that all the required records have been seen and are satisfactory, with the dates checks have been requested and returned. The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be confident that the home is well-run and managed in their best interests, promoting and protecting their health, safety and welfare. EVIDENCE: The registered manager has been in post for several years and has achieved her National Vocational Qualification (NVQ) level 4 in management and care. She has continued to undertake further training to develop her knowledge and skills and has just completed a Certificate in Community Mental Health. She has plans to undertake a counselling skills course next. The manager demonstrated in discussion that she has the relevant knowledge and skills to achieve the aims and objectives specified in the home’s statement
The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 23 of purpose. There is currently a wide age range of residents, some of whom have complex needs relating to their mental health and physical disabilities. The manager makes sure that staff work with residents in a person centred way and that they are equipped to deal with residents’ diverse needs by training and well structured supervision. Since the last inspection, the management have worked hard to develop the home’s quality monitoring systems. A quality assurance report for 2006 has been produced, demonstrating that residents’ and staff views have been sought via satisfaction questionnaires, with a good analysis of the results. An action plan has been devised that identifies improvements for the year that the home is currently working through. Health and safety monitoring checks have been further developed over the past year, including weekly and monthly house checks carried out by designated staff. These are then fed into three monthly manager checks, which are all well recorded. The registered provider visits the home regularly and residents reported that he is very approachable and spends time talking with them. Likewise a staff member confirmed this. However, the provider has not yet instigated the formal monthly visit reports that he is required to do. Therefore this element of the last inspection report requirement still needs to be actioned. The manager indicated that the provider had thought that the monthly health and safety checks that he monitors during his visits fulfilled this obligation. She agreed to speak to the provider to explain what is needed. The manager confirmed that the home’s equipment has been serviced and all maintenance and safety checks are up to date. The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x x 3 x The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA20 Good Practice Recommendations It is recommended that a review of the medication storage is carried out with reference to the Royal Pharmaceutical Society guidance and to make sure that the storage facilities comply. To ensure there is sufficient space for all medications to be appropriately stored and that internal and external medications can be kept separate. The Wimbledon DS0000058572.V345772.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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
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