Inspection on 27/06/06 for The Worthies

This inspection was carried out on 27th June 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Worthies 01/04/09

The Worthies 02/04/08

The Worthies 03/05/07

The Worthies 25/11/05

The Worthies 04/05/05

The Worthies 11/01/05

The Worthies 28/06/04

The Worthies 11/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Worthies 79 Park Road Stapleton Bristol BS16 1DT Lead Inspector Sandra Jones Unannounced Inspection 09:30 27 June & 14th July 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 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 Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Worthies Address 79 Park Road Stapleton Bristol BS16 1DT 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) 0117 9390088 0117 9655881 The Worthies Residential Care Home Ltd Ms Shenaz Bi Butt Care Home 24 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (19) of places The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 24 persons aged 65 years or over Date of last inspection 25th November 2005 Brief Description of the Service: The Worthies is a 24-bedded home registered to accommodate 19 people who are elderly and 5 older people with dementia. The home is situated on a bus route, fairly close to shops, libraries and health centres. The accommodation is arranged over three floors, with shared space on the ground floor and bedrooms on all floors, accessible to all floors by a passenger lift. The fees range from £348.00 - £415.00 per week. The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted two days in June and July 2006 and focused on the assessment of key standards of care. Residents and relatives comment cards were used in advance of the site visit to seek their views on the standards of care. The records were examined and a tour of the premises took place to make judgements on the standards of care. The views of the residents were sought during the inspection to confirm the care practices at the home. What the service does well: What has improved since the last inspection? The carpets in the lounges were changed and the dining area was repainted with curtains replaced, which has brightened up these areas and made it more homely. The Statement of Purpose was updated to better enable potential residents, their relatives and placing agencies to make choices about living at the home. Training has become more structured about the skills and insight needed by the staff to meet the changing need of the residents. Dementia, challenging behaviour and mental health will ensure that staff can meet the residents’ The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 6 category of needs. Staff are encouraged to undertake external qualification beyond the National Minimum Standards (NMS) of 50 of the staff team. The introduction of social care programmes will ensure that residents will have opportunities to pursue hobbies and interests 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 Worthies DS0000026524.V294401.R01.S.doc Version 5.1 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 Worthies DS0000026524.V294401.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 &6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service EVIDENCE: The home’s Statement of Purpose describes the admission process. Within the procedure are the criteria for admission at the home including the arrangements for introductory visits and trial periods. Residents’ surveys were sent to the home and nine of the thirteen responses received confirmed that information is provided in advance of admission to the home. In terms of the assessments to be conducted in advance of the admission, the pre-admission policy describes the procedure to be followed, with the approach and responsibilities towards the residents. This policy must be updated to ensure the steps to be followed apply to the home. Seven individuals were admitted to the home since the last inspection and the case records of two recent admissions were examined. The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 9 It is evident that initial assessments based on personal information, medication, physical and mental health care needs are conducted. The records illustrate that admissions to the home are based on full assessments. Intermediate care is not offered at the home. The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The service provider must continue to develop the care planning process to achieve a person centred approach to meeting needs. Residents health care needs are continuously assessed by the staff, which are recognised and where appropriate health care services are accessed. Safe practices of medication administration, ordering and recording exist at the home. Guidelines for the administration of “when required” medications must be developed. Residents feel that members of staff respect their rights to privacy and dignity. The procedure for privacy and dignity would benefit from the inclusion of staff’s expectation towards meeting residents rights. EVIDENCE: Case records examined contain, pre-admission assessments conducted by the service provider, home’s care plans devised from the assessments and where appropriate care managers’ core assessments are in place. It was the previous practice of the home to develop core care plans for each person. The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 11 However, the practice is institutional and is not specific to the individual. Action plans must be developed from the assessments conducted by the home, core assessments received and information sought about the individuals likes/ dislikes and preferred routines. For the second day of the inspection, the service provider restructured the care planning process. The information sought from other sources was augmented to formulate an action plan that included important and essential information, with the support necessary to meet the identified needs. Within the case records the individual profile lists the preferred routines, likes and dislikes about meals and drinks. Personal hygiene, daytime and nighttime routines are included, with additional information about meeting residents’ physical and mental health care needs and mobility. Staff consulted during the inspection, reported that key workers are involved in the care planning process. They generally, undertake tasks identified within the care plans. The designated key worker evaluates care plans on a monthly basis and whenever changes occur, the service provider amends the care plans. Reviews take place every six months and generally convened by the service provider or care manager. The records of the review meetings indicate that the resident is always present and relatives are invited. Dependency assessments which focus on the individuals needs based on their mobility, continence, physical care and communication needs are completed for each person. From the assessment, the person’s level of dependency is ascertained. Where dependency levels are assessed as medium or high, care plans are more extensive in the area of need. Nutritional assessments are completed for residents whose weight requires monitoring. Where there is cause for concern and high risk factors are identified, a care plan for poor appetite is formulated. Mental health care assessments are developed on the identified need. Handling assessments are completed for each person to assess their mobility needs. An accident risk assessment then follows with an action plan to minimise the risk. Residents are registered with a GP. A record of the request for GP’s visit is maintained with a separate record of the visits conducted and their outcome. Where the person has not seen a health care professional for twelve months, a check-up is requested by the home. Chiropodists visit the home six weekly, dentist appointments are arranged to the practice when required and the optician visits the home six monthly. Three residents have district nurse input, two are for dressings and one is for three monthly injections. Two residents attend hospital appointments and the service provider stated that previously staff would accompany residents. The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 12 Since the changes with ambulance transport, relatives are encouraged to accompany their relative. The home maintains an accident record. The service provider explained that the Health Visitor has assessed nine residents that have continence difficulties. There are six monthly reviews undertaken to ensure that the correct continence aids are provided. The Continence Advisor provides training to all staff about managing incontinence at the home. It was understood from the service provider that residents with a history of falls are not currently accommodated. One person requires assistance with moving and handling and individuals that use zimmer frames’ to maintain their independence are accommodated. It is the policy of the home that residents that staff walk with residents that use zimmer frames. The service provider reported that a graduate psychologist is providing courses to raise awareness on residents’ complex needs. Depression, aggression, dementia are areas covered to develop a person centred approach to meeting their mental health care needs. From the person centred activity a social care programmes are introduced. Medications are administered through a monitored dosage system and the records indicate that staff sign the records immediately after administration. The record of medications no longer required is countersigned by the pharmacist to indicate receipt of the medication for disposal. There is a separate system for recording the administration of controlled medications and the records were found to be accurate and up to date. “When required” medications are administered from standard packaging. It was understood from the service provider that permission must be sought from the deputy or service provider before the staff in charge can administer the medication. Individual guidelines for administering “when required” medication must be devised to ensure these medications are correctly administered. The arrangements for Privacy and Dignity are denoted within the Statement of Purpose along with the home’s principles of care. The procedure for Dignity and Privacy would benefit from further development by including more information on staff’s expectations towards residents privacy and dignity. The residents giving feedback during the inspection confirmed that staff respected their rights to privacy and dignity. The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The introduction of social care programmes will ensure that residents will have opportunities to pursue hobbies and interests. Members of staff support residents to strength links with family and friends. Residents are able to exercise choice over their lives at the home. Residents confirmed that the meals served at the home are good and there is a varied menu. EVIDENCE: It was understood from the service provider that Social Care programmes were introduced following psychologist input into specific areas for meeting residents’ needs. Key workers were given the responsibility to consult with their key residents past history, interests, likes and dislikes. From the questionnaires a personal profile is compiled about the person’s hobbies, interests and leisure activities. There is a brief description of the activity, their benefits, with the persons ability to undertaken the tasks. A report is then formulated by the key worker about the activity undertaken. The deputy manager and service provider will monitor the activity programmes to ensure that the residents pursue their leisure interests. The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 14 Entertainers and physiotherapists visit the home monthly to provide organised entertainment. Structured entertainment occurs fortnightly at the home and during the inspection, music for health session took place with the physiotherapist. Thirteen responses were received from residents and six felt that activities were sometimes arranged. A minibus was recently purchased to provide outings for residents. Trips to places of interest and theatres are to be organised in the near future. Although visitors are welcome to the home at all times, there is a request that visits during mealtimes are avoided. Seventeen surveys were received from relatives/visitors before the inspection. Positive responses were received about the welcome received whenever visits take place at the home. It was also confirmed that visits can take place in private. The Statement of Purpose details the Aims and Objective of the home, which include the Principles of Care. Residents are invited to have personal possessions in their bedrooms. Regarding confidentiality the Statement of Purpose describes the arrangements in place to maintain information secure. In terms of advocates, the agencies that can be contacted to access advocacy are included within the Statement of Purpose. Catering staff were consulted during the inspection, it was reported that catering staff and the service provider discuss the meals to be served. From this discussion a four-week menu is then prepared. There is a choice of meals at each mealtime and before each mealtime, staff ask residents their preferences. A record of meal provided is maintained at the home, which indicates that residents have choices at each mealtime and a varied diet is served. It was reported by the catering staff that three residents have cultural needs in respect of the meals. One requires a Jewish diet and two prefer Caribbean meals. The person that requires a Jewish diet informs staff and requires reassurance that the meals meet the set boundaries. For the residents that prefer Caribbean meals, West Indian meals are prepared twice weekly. The range of frozen, fresh and canned foods reflected the menus in place and supported that the residents have a varied diet. Residents’ responses through the questionnaires indicated that the meals are always good. During the inspection, residents’ feedback was sought and positive comments about the meals were also made. There was a recent Environmental Health Officer (EHO) visit to the home and the contraventions identified were actioned. The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The service provider ensures that the Complaints procedure is accessible and residents’ views are sought at the home. It is evident from the systems in place that there is a commitment to safeguarding residents from abuse. EVIDENCE: The Complaints procedure on display in bedrooms is in large print to ensure the residents can read it. Thirteen people responded through surveys and seven indicated that they knew the procedure for making complaints. Eleven of the seventeen relatives comment card received indicated that they knew the procedure for making complaints. Residents consulted knew the procedure for making complaints and would approach the service provider with complaints. There was one complaint received at the home by a resident since the last inspection. From the complaint received, one member of staff was subject to disciplinary action. The service provider has retained a copy of the letter inviting the member of staff to a disciplinary meeting. The disciplinary process was explained in the letter including any action that would be taken for non-attendance. The member of staff did not attend the meeting and the service provider will be informing the individual in writing, of the outcome of the meeting that occurred in their absence. The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 16 The home’s Abuse policy was updated to instruct staff on the actions to be taken for alleged abuse, which follow “No Secrets” guidelines. Members of staff have attended external POVA training and during consultation, the staff confirmed that they attended the training. The deputy manager and service provider have attended the external POVA course for managers and service providers. The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The Worthies is homely and comfortable. The combined communal areas provide residents with sufficient seating to socialise in groups. There is continuous of the equipment to ensure residents maintain their independence. The premises are kept clean and free from unpleasant smells. EVIDENCE: The Worthies is located in Stapleton Village close to bus routes and fairly close to shops and library. The accommodation is arranged over three floors with bedrooms on all floors and shared space on the ground floor. The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 18 Shared facilities comprise of three lounges are sited at the front of the property. Overall there were twenty individuals sat comfortably in the three lounges with a further three people sat in the seating area within the dining room. In the dining room there is sufficient seating for the residents to have their meals together. With two exceptions, bedrooms are single. The double bedrooms are en-suite offering privacy with personal care. Bedrooms contain a combination of the home’s furniture and personal belongings and are furnished and equipped to meet the needs of the individual. Privacy is promoted through lockable doors with additional lockable space in bedrooms. Residents consulted were positive about their bedrooms. It was confirmed that residents can have their personal possessions in their bedrooms. There are toilets on each floor and a bathroom on the second and third floor. The two double bedrooms have are en-suites with showers. It was noted during the tour that the locks on bathrooms and toilets required attention. Equipment and aids are provided to assist less mobile residents with moving around the home. Residents have access to bedrooms and shared space by the provision of a passenger lift to the first and second floor and level access into the building. Since the last inspection a hoist was purchased to maintain residents independence and dignity. The laundry room is sited away from the kitchen. The floor covering and walls are impermeable making surface readily cleanable. There is an industrial and small domestic washing machines with specific programmes for sluicing and two tumble dryers. The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The staffing levels are adequate to meet the needs of the current residents. To ensure residents’ protection, the authenticity of the referees must be sought through the request for references format use by the home. The training programme will ensure that the staff are competent to meet the residents changing needs. EVIDENCE: Three staff are on duty throughout the day with ancillary staff for cooking and cleaning. At night there are two staff undertaking waking duties at the home. The service provider is in day-to-day control of the home with the deputy and nine senior care assistants. The deputy manager and nine care assistants can be left in charge of the home whenever the service provider is not at the care home. Fourteen staff are currently employed at the home. There is an expectation that members of staff undertake vocational qualification and currently with the exception of one, all staff are registered onto the training. The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 20 Four staff were recruited since the last inspection and their personnel files were examined during this site visit. Completed application forms, written references and Criminal Records Bureau (CRB) disclosures were in place for two staff. It was understood from the service provider that the staff without CRB are working supernumerary and not undertaking personal care. In terms of the application form, the service provider has introduced a more stringent form to ensure the recruitment process is robust. The requirement to ensure the validity of the referee, is sought through the standard request for references, remains outstanding. The service provider must ensure that where standard request for reference letters are used, the validity of the referee is sought. Members of staff are provided with copies of the Social Care Council Code of Practice. The staff must sign to indicate receipt of their copy and their understanding of the code. The home follows as part of the induction for new staff a familiarisation of the property, care of the residents and home’s routines programme. The service provider presented a booklet that will be introduced to enhance the in-house induction. While the induction programme is detailed, the service provider must ensure that Skills for Care guidelines are followed. The service provider stated that currently staff are undertaking vocational qualifications and updating statutory training. Since the last inspection, staff have attended Continence training and courses in Depression, Communication and Menu planning. It was further explained that as senior staff have undertaken courses in dementia, challenging behaviour, depression and sexuality, the training will be extended to all other staff working at the home. These courses will then become part of the training programme for the staff employed at the home. Members of staff consulted confirmed that the service provider encourages training. It was explained that there is an expectation that staff attend training relevant to their roles. It was understood from the staff that they must attend update statutory training. The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 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): 31,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The recruitment of a part time manager will benefit the forward planning of the home. The systems in place safeguard residents’ financial interests. The routine checks and practices promote the safety of the residents and staff at the home. EVIDENCE: The service provider has completed the NVQ level 4 and will be undertaking the assessor’s course, as well as continuing with the degree course in Care of the older person. The service provider has purchased another care home and a part-time manager will be recruited to assist with the day-to-day running of the home. The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 22 Facilities for the safekeeping of cash and valuable exist at the home and a sample of the cash held in the home was checked. The records contain a brief description of the transaction and cash balances were consistent with the balances held. A record of fees charged at the home is maintained with the sources that contribute towards the fees. Fees range from £348.00 - £415.00 per week. Service certificates for the lift, portable equipment, with heating and boiler documentation of checks conducted by contractors, indicates that residents and staff’s safety are promoted. The records that relate to fire safety procedures, checks and practices were examined and indicated that checks and practices are conducted at the stipulated frequencies. The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 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 OP1 Regulation 15 Requirement An action plan must be developed to guide staff to meet residents’ needs. For residents with dementia, care plans must detail communication and safety needs. Within the care plans residents’ likes, dislikes, preferred routines and abilities must be incorporated. Recreational activities must be included within the care plans and reviewed. The arrangements for Privacy and Dignity require further development in terms of the staff’s responsibilities. The Pre-admission policy must be updated to ensure the steps to be followed apply to the home. Risk assessments must be completed for locking the front and rear entrance to the home Guidelines for the administration of “when required” medications must be developed DS0000026524.V294401.R01.S.doc Timescale for action 30/10/06 2. OP10 4.Sch.4.1 8 4.(1)(c) Sch.1.8 30/10/06 3. OP1 30/09/06 4. OP9 13(4)(a) 30/10/06 5. OP9 13(2) 30/09/06 The Worthies Version 5.1 Page 25 6. OP29 19 The references from the current/most recent employer must be sought and their must authenticity established. (Previously required 04/04/05 & 25/11/05) 30/10/06 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 Worthies DS0000026524.V294401.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Worthies DS0000026524.V294401.R01.S.doc Version 5.1 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!