Inspection on 20/03/07 for The Withins Residential Home

This inspection was carried out on 20th March 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Withins Residential Home 19/02/09

The Withins Residential Home 20/10/06

The Withins Residential Home 30/01/06

The Withins Residential Home 15/09/05

The Withins Residential Home 01/02/05

The Withins Residential Home 20/07/04

The Withins Residential Home 22/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Withins Residential Home 38-40 Withins Lane Breightmet Bolton Lancashire BL2 5DZ Lead Inspector Stuart Horrocks Unannounced Inspection 20th March 2007 09:00 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 Withins Residential Home DS0000009310.V320703.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. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Withins Residential Home Address 38-40 Withins Lane Breightmet Bolton Lancashire BL2 5DZ 01204 362626 01204 381240 withinsresthome@aol.com 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) Withins (Breightmet) Limited Mrs Janet Carr Care Home 65 Category(ies) of Old age, not falling within any other category registration, with number (65) of places The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission. 20th October 2006 Date of last inspection Brief Description of the Service: The Withins is a large, purpose built, private residential home providing personal care and accommodation for up to 65 older people. The home is privately owned and registered under the company name of Withins (Breightmet) Limited. The home is located in a residential area in Breightmet, about 2 miles from the centre of Bolton and may be reached by public transport. There are shops, pubs and other amenities nearby. Accommodation is provided on three floors and there is good wheelchair access throughout the home. All bedrooms are single and have en-suite facilities. A passenger lift provides access to all three levels of the home. There is a dining room and lounges on each floor and each floor is provided with bathrooms, a shower room and toilets. Garden and patio areas are well maintained and accessible to residents. A Service User Guide (Residents Information Guide) that describes the home’s services is available in the home and prospective and new residents and their families are provided with a copy of this document. The staff also give other information about the home to the above people verbally. A copy of the latest inspection report and the home’s Statement of Purpose are also displayed in the home. As of March 2007 the weekly charge for accommodation and services is between £344:00 and £350:00. Additional charges are made for hairdressing, private chiropody services and personal magazines and newspapers. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which included a site visit that was started at 9:00am on the 20th March 2007. It took place over one day and it lasted for about seven and half hours. The time was split between talking to the Manager, the Deputy Manager and checking records, looking around the home, watching what was happening and talking to residents and other staff. Four residents and six staff were spoken with. A completed pre-inspection questionnaire was received along with feedback surveys from four doctors. The care services (case tracking) provided to four specific residents were used a basis for the process of the inspection. What the service does well: The residents said that they were well looked after by the staff who they described as being “helpful”, “caring”, “friendly” and “easy to get along with”. The residents looked well cared for and proper arrangements are in place that ensures the residents health care needs are monitored and met. Individual care plans are in place, which provide the staff with the information they need to give a good standard of care. During the inspection the staff were seen to deal with the residents in a comfortable, caring and natural manner. Before admission to the home new residents needs are properly checked so that the home can be sure that these people can be properly cared for. The home has a good activities programme that the residents said that they enjoyed that helped to keep them stimulated and motivated. The residents enjoy the meals, special food is provided for those people who need it and those residents who cannot eat by themselves are given help. The home has a natural, friendly and homely feel about it with staff spending time talking to the residents. The residents are treated with respect and their privacy and dignity is upheld and they are helped to make choices and decisions. Visitors are welcome and the residents have choice about their daily routines, spending their time doing whatever they prefer. The building is well looked after and clean, and it is safe. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 7 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 Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 8 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. Quality in this outcome area is good. Pre-admission visits, and the initial assessment process, enable all parties, including potential residents and their relatives, to reach a decision as to whether the home will be able to meet their needs. This judgement has been made using available evidence including a visit to this service. The home does not provide intermediate (rehabilitative) care so Key Standard 6 does not apply. EVIDENCE: The care files of four residents recently admitted to the home were checked for the required pre-admission needs assessment information. Such assessments were seen to be in place that demonstrated that the admission procedure was thorough and checking of the above records showed that a full assessment of these residents care needs had been completed prior to their admission to the home. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 9 The manager or a senior member of the staff usually visits new residents either at home or in the hospital as a part of the assessment and admission process. Evidence of this was seen in the above checked files. From the above information the home is then able to assess whether these people’s needs can be met and a care plan and a range of other care delivery information is then put together. Where practical, new residents and their families are welcome to visit the home where they can spend some time and meet the residents and the staff. At the time of the last inspection a requirement was made under these standards that home was possibly operating outside their conditions of registration due to the fact that some residents may be inappropriately placed due to their medical condition. The home has since contacted the CSCI and was advised that that they were not in breach of their registration conditions and that there was no need to vary the registration. However the inspector reminds the manager that the home should only provide services to people listed within the home’s registration categories and that the home must be able to meet prospective residents needs. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 10 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. Individual care plans are in place, which were up to date, regularly reviewed and provided the staff with the information they needed to give a good standard of care. The home’s medication systems are satisfactory in ensuring that residents received medication as prescribed and care practices in the home ensure that the residents are treated with respect and their privacy and dignity is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care files of the four case tracked residents were looked at. These contained care plans that had been kept up to date monthly as is required. The care plans are properly laid out and they are easy to read and follow. Each plan contained details of health, personal and social care needs for the resident. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 11 All of the above records also showed that the residents weight is also checked regularly. The staff said that they knew each residents needs by reading the care plans, which are readily available to them. Day and night progress reports about each resident are regularly recorded and as required at the previous inspection the staff have been given instruction about proper report writing. A recommendation previously made was that all information relating to the residents should be kept in their care files and not displayed on notice boards. This recommendation has now been dealt with, with no evidence of the above being seen by the inspector during this visit. A requirement made at the time of the last inspection was that resident’s risk assessments must be kept up to date. Such risk assessments were found to be in place for safe manual handling (under mobility care plan) and nutrition (under dietary care plan). Both of these were found to be up to date and to be being reviewed regularly. Pressure sore risk is assessed by direct observation by the staff with any problems being referred to the community nursing staff for advice and treatment. Talking to residents, the manager and the staff and looking at records and survey documents showed that the resident’s health care needs are taken care of and that when necessary health workers such as doctors, nurses and opticians are called. A requirement made at the time of the previous inspection was that the appropriate use of wheelchair lap safety belts must be assessed by an suitable professional and the effectiveness monitored. Following such professional discussion the home now only uses such lap belts whilst those residents requiring wheelchair transfer are actually being moved around within the home. A further requirement made was that the home must ensure that medications are administered safely. The inspector’s enquiries showed that this requirement has been addressed. All medicines were safely stored and lockable Controlled Drugs storage is also available and the random checking of these found the quantity kept corresponded as required with the amount recorded in the Register.. The residents’ medicines are provided in pre-filled blister packs with preprinted prescription/recording sheets also provided. These records were found to be properly completed and to be up to date. The medications supplied are checked in to the home , and medicines returned to the pharmacy are also recorded. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 12 Identification photographs of each resident are kept with the medication administration records. The home has a satisfactory medicines policy and procedure that includes guidance for the self-administration of medicines and the use of homely remedies and those staff that give out medicines have been given the necessary training for this task. In discussion the residents said that they are given their medicines regularly and as prescribed. No resident was dealing with their own medicines at the time of the inspection. Paperwork looked at reinforced the importance of staff treating residents with respect and dignity. Residents spoken with were all complimentary about how staff assisted them with personal care tasks and felt their privacy and dignity was respected at all times. This was also observed during the inspection. Residents were asked quietly if they needed the toilet, they were taken without having to wait, toilet doors were closed and staff knocked on bedroom doors before entering. Those residents spoken with said that the staff were “courteous”, “caring”, “lovely” and that “they (the staff) talk to us properly”. The staff were seen to have a good relationship with the residents, speaking to them in a natural, thoughtful and warm manner. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. Residents have choice about their daily routines and they are able to spend their time as they wish. Visitors are welcomed and the meals provided are good, offering choice and variety, and catering for special dietary needs. The activities offered within the home mean that residents have opportunities to participate in stimulating and motivating activities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs two activities workers who organise and implement a programme of social and recreational activities for the residents. This programme includes events such as craftwork, gentle exercises, ball games, bingo, sing a longs, board games and outings to various venues. Forthcoming outings include lunch at Botany Bay, a Lancashire lunch at Smithills and a trip to Bolton Museum. The morning and afternoon activities programme is displayed, which those residents spoken with were well aware of and they chose to join in as they pleased. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 14 Up to date records were seen to be in place of when the residents have joined in with activities From talking with residents and staff the inspector confirmed that visitors are welcome at any time, although preferably not at meal times. Those residents spoken with said that they “were free to see their visitors wherever they wanted to”. They described taking visitors to their bedrooms for privacy or seeing them in the main lounge. The residents said that visitors are made welcome and that they (the visitor) can have a warm drink if they so wish. Residents felt their routines were flexible and that they had choices in where to sit in lounges and dining rooms, whether or not to take part in activities, what to wear and times of rising and retiring. For those residents who may have a limited ability to make decisions and choices about their day-to-day living arrangements the staff said that they try to assist them with this by offering choices about such things as what clothing to wear, when to rise and retire and helping to choose from the menu. The residents are able to, and do bring personal items in to the home such as televisions, radios, photographs, pictures and ornaments. The home has a four weekly menu that offers a choice of good nourishing food with the main meal served at lunchtime and a lighter meal at teatime. Warm food is always offered at midday and a warm choice is usually available at teatime. The residents praised the food served generously saying that the food was “good”, “appetising”, that “you get enough to eat” and that “you can have something else” if you don’t want what is on the main menu. The residents also said that drinks and snacks were available at most times if the day. Meals were seen to be presented in an appealing manner with good portions offered. They are eaten in the dining rooms provided on each floor that are nicely furnished that provide a comfortable setting for the residents to dine. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. The home has a clear complaints system that ensures that concerns are properly dealt with and good protection of vulnerable adults guidance and the continued staff training in this topic makes sure that residents are protected from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is included in the service users’ guide and is also displayed in the entrance to the home. The facility of contacting the local CSCI office is also included in this documentation. Discussion with residents showed that they were aware of the above procedure and they would feel comfortable about raising concerns which they believed would be listened to and acted upon. It was clear in discussion with staff that they knew what steps to take should a resident make a complaint. A number of staff said that if “they couldn’t sort things out at the time” then they would inform the manager about the problem. A complaints file is kept which records the details of any complaints made, of any action needed to deal with the complaint and of the outcome. One complaint has been made directly to the home since the last inspection in October 2006 that has been properly dealt with. No complaints have been made to the CSCI during the above period. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 16 There are written procedures and policies covering adult protection, whistle blowing, the none acceptance of gifts, borrowing money and legacies and the home has a full copy of the Bolton inter-agency safeguarding adult protection policy and procedure. A requirement of the last inspection was that the staff must be provided with training in adult protection procedures. Examination of training records showed that a considerable number of staff have received instruction about this topic and that further such training has been arranged for April and May of 2007. All of the six staff spoken with demonstrated an awareness of the different sorts of abuse and they understood what they should do if they suspected that someone was being abused. Discussion with the manager showed that when incidents arise they are dealt with promptly. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. The Withins provides clean, safe, comfortable, surroundings for the people living there. homely and friendly This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Withins is well maintained both to the inside and to the outside. The home is bright and welcoming. Decoration, furnishing and lighting is to a high standard and is domestic in style. The four case-tracked resident’s bedrooms were checked. All were found to be decorated, furnished and equipped to a high standard and these residents said that they were satisfied with the level of the accommodation provided. There is good accessibility around the building with ramps,assisted baths and other equpment provided. Aids and adaptation are provided in bedrooms, bathroom and toilets. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 18 The home has a properly equipped laundry and the staff have been provided with training about the control of infection. Residents clothing is marked to enable easy identification and the residents had no complaints about the laundry service provided by the home. The home was clean and tidy throughout and was free from any offensive odours therefore providing a pleasant place to live. A requirement made at the time of the last inspection was that a defective light switch in a dining room must be repaired. This work has been dealt with. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is adequate. Staffing levels are satisfactory, good staff training is provided but improvements in staff recruitment are needed to make sure that the residents are looked after by staff that are suitable to carry out care work. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Looking at staff rotas showed that as well as employing care staff, the home also employs domestic, administrative, catering and maintenance staff. Two workers are also employed who plan and arrange recreational activities for the residents. Those staff interviewed described a settled staff team with good morale and they said that they enjoyed working at the home and providing care for the residents. The rotas indicated that nine care staff are on duty in the morning, eight in the afternoon and evening period and four staff are on duty during the night. The staff and the manager were clear in stating that in their opinion there was enough staff to meet the needs and dependency levels of the people living at the home. The home was required to have 50 of the care staff with NVQ level 2 qualifications or above by the end of 2005. Of the 36 care staff employed at the home 26 have got a National Vocational Qualification at Level 2 or above The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 20 with four other members of staff presently undertaking NVQ assessment at this Level. 73 of the staff is therefore trained to the required level with the above target being exceeded. A requirement of the previous inspection was that the home must operate robust staff recruitment procedures. The files of four recently recruited staff and one other were checked for the required safe recruitment information. Although these files showed that staff recruitment has improved since the last inspection these files did not fully evidence a safe and proper recruitment system. All of the files contained a job application form, an up to date police check, health and criminal declarations and proof of identity, but in two instances only one instead of the required two written references, had been obtained. A requirement of the previous was that the home must provide the staff with training in the care of people with psychological (dementia) care needs. The home has a staff-training chart that shows both when training has been provided and when training is required. Looking at this chart showed that the majority of the staff have been provided with the required mandatory training (safe moving and handling, fire safety, infection control, food hygiene and first aid) and that many staff have also received training in the care of people with dementia care needs. Further staff training is also planned in the topics of safe moving and handling, safe wheelchair use and adult protection. The home also operates a training programme for the induction of new staff that complies with the recommended Scils for Care Common Induction Standards. The provision of all of the above-described training was confirmed when talking to staff. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38. Quality in this outcome area is good. The manager of the home provides leadership and support for the staff to ensure that the residents receive a satisfactory standard of care and a satisfactory accounting method is used, which protects the resident’s interests. Procedures and practices within the home promote and safeguard the health, safety and welfare of the people living and working in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home manager (Mrs. J Carr) has been approved and registered by the CSCI and she has been responsible for the running of The Withins for over five years and Mrs Carr has completed the required Registered Manager’s Award. The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 22 The home is run in a satisfactory manner and discussion showed that the manager knows the residents and the staff well. The residents and the staff said that the manager operates the home in an open and inclusive way and that she is fair-minded, approachable and easy to get along with. A requirement of Standard 33 is that care homes must use quality assurance systems that are largely based on seeking the views of residents to measure their success in meeting the home’s aims and objectives. This information can then be used if necessary to bring about changes or improvements to the service. The method that the home currently uses for this purpose is that where resident’s and relative’s questionnaires are permanently available in the home’s entrance area with these being placed in the suggestions box as they are filled in. These were last brought together in July 2006 when a brief report on the findings was produced. The inspector feels that this method of obtaining people’s views about the service is somewhat erratic and that a more formal system should be considered. This was discussed with the manager at the time of the inspection with agreement being reached about developing such a system and it was also agreed that when the results have been analysed a report will be put together and displayed in the home. The inspector was told that the home holds meeting for residents and relatives twice yearly and that some internal quality audits of the home’s systems are undertaken for items such as residents care plans, the medication arrangements and general maintenance. A number of survey questionnaires were sent out by the CSCI to the residents, relatives and health workers (GP’s, district nurses etc) before the inspection. These questionnaires give these people the opportunity to comment upon various aspects of the services provided by a care home. At the time of writing this report four questionnaires had been returned by doctors who visit the home. Although three of these people expressed satisfaction with the level of communication, administration of medication and the overall care provided one person did raise some issues, which were discussed with the manager during the inspection. The home holds money for a number of residents for safekeeping. This system was checked with the details found to be properly recorded. The money is held in a “pooled” bank account with the total and individual balances being recorded in such a way that these can be readily checked and verified. This bank account is only used for the holding and transactions of residents’ funds and it is clearly identified with the bank as a residents’ fund account. A recommendation made at the time of the last inspection was that the care staff should receive formal recorded supervision at least six times a year. These supervision sessions give staff the opportunity to meet with their The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 23 manager at regular intervals to discuss their work, development and possible training needs. The manager has now compiled a list of staff supervision dates that runs throughout 2007, written evidence was seen of such supervision meetings and all of the six staff interviewed confirmed that that they had had formal supervision recently. The home is safely maintained with fire precautions tests done regularly and a random check of the accident book showed that the details of accidents are properly recorded. Information obtained from the pre-inspection questionnaire showed that the homes fixtures, fitting and equipment is properly maintained and regularly serviced. Looking at records and conversations with staff also showed that the necessary training had been provided so that they can work safely. The Withins Residential Home DS0000009310.V320703.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 X 3 X X X 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19 (1) Timescale for action Staff must be recruited properly 30/04/07 and safely so making sure that the residents are looked after by people that are that are suitable to carry out care work. (Previous timescale of 01/12/06 not met) The homes quality assurance 30/04/07 processes must be carried out regularly so that the home can measure its success in meeting the residents’ needs. Requirement 2. OP33 24 (1) (2) (3) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Withins Residential Home DS0000009310.V320703.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 The Withins Residential Home DS0000009310.V320703.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!