CARE HOMES FOR OLDER PEOPLE
Walcot Hall Walcot Green Diss Norfolk IP22 5SR Lead Inspector
Mrs Judith Huggins Announced Inspection 15th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Walcot Hall Address Walcot Green Diss Norfolk IP22 5SR 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) 01379 641030 01379 644511 Saxlingham Hall Nursing Home Limited Ms Susan Doherty Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 03/05/05 Brief Description of the Service: Walcot Hall provides nursing care for older people. The Home is situated in a small hamlet adjoining the market town of Diss. The original building is a two storey detached property built in the 18th. Century and has been extended to provide an additional wing of 18 beds. It is set in three acres of ground with a small lake in the lawned area of the gardens. The Home is accessible by road and the nearest rail station is in Diss. Parking is available in the small car park and adjacent road. There is a twice daily bus service from a near by bus stop into town. It would be beyond walking distance for older people. Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was announced and lasted 8 hours. Information was taken from records checked, the pre-inspection questionnaire, and discussion with the manager and proprietor. Sitting and dining areas, some bedrooms, the laundry, kitchen and exterior of the home were looked at. Additionally, four members of the care team, three ancillary staff, four residents and two visitors were spoken to. Regrettably, few comment cards from relatives were completed and so these were again “circulated” after the inspection. Six were received at the point of drafting the report and the views expressed incorporated where appropriate. One resident comment card was returned with an anonymous staff complaint and has been addressed separately. Five others were received (although written comments on one of these says it is from a staff member and the views have not been included in the report as those of a resident). Two comment cards were received from visiting health professionals The home has changed hands since the last inspection and has a new registered owner and manager. They have attempted to address requirements made of the last registered persons but were not able fully to do so until August, when they became registered with the Commission and took over full ownership of the home. For this reason, a number of requirements made at the last inspection have not been revisited, but need to be borne in mind by the current owners when they are planning the work needed to meet standards and regulations. These requirements may be repeated at future inspection(s). What the service does well: What has improved since the last inspection?
The new owner took over a home with significant problems and has already identified and addressed some of the shortfalls. Although there is further work to do, progress has already been made.
Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 6 Both visiting health professionals comment that there has been an improvement in communication and efficiency since the new owners took over the home. One considers that information relating to patients’ problems is more readily available. There has been investment in upgrading parts of the building. Some rooms have been redecorated and had new carpets fitted, and the dangerous carpet on the main staircase has been replaced. A new room has been provided for the storage of medicines, a new office is being created, and the administrator already has a dedicated office space. There is more work planned which will help improve the environment for residents. Two new hoists have been acquired to help with safely moving and handling residents. Some new beds have been obtained, and there are more pressure relieving cushions to help reduce the risk of vulnerable people developing pressure sores. The complement of trained nursing staff has been increased. A relative responding with written comments says that the staffing levels have improved under the new owners (although see also below). Enforcement action was taken against the former registered persons, for poor management of medication. Since the last unannounced inspection, an unannounced visit has been carried out by the pharmacy inspector and allocated inspector for the home, showing that the new owners have improved systems to ensure that residents’ medication is managed properly. The undergrowth to the rear of the home, where the first floor fire staircase emerges has been cut down, the pond has been dug out (and its appearance will be much improved when it re-fills), and the area has been fenced. What they could do better:
Given the change of ownership and responsibility, the new management team has had considerable work to do to identify and address shortfalls in the service in addition to those identified at inspection. Work has already been undertaken and it is acknowledged that staff and the manager are frustrated in some regard by the length of time this is taking. The manager and owner acknowledge that they still have some way to go but are committed to improving the service. The proposed care plan system, ready for implementation, needs to provide for discussion with residents about their needs and wishes, in respect to overall care but also taking into account recreational and social needs. These are not addressed fully at present with half of residents and one relative feeling that more appropriate and stimulating activities are needed. Pending refurbishment of the kitchen (a long term project), there may be a need to review and be more specific about cleaning schedules so that food
Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 7 safety is enhanced. Advice and support will be needed from environmental health to ensure that standards are maintained until the refurbishment. Half of the residents responding do not like the food so there is a need to discuss this area more fully with people living at the home. One resident completing a comment card (25 ) does not know who to speak to if they have concerns about their care, and five (83 ) of relatives responding do not know what the procedure is for making a complaint. This area needs to be addressed so that the new management team can be sure they are dealing with concerns as they develop and improving the service for residents as a result. There have been occasions, based on discussion with the manager and staff, when staffing levels have fallen below the minimum acceptable levels. The management team are attempting to address staffing issues, including difficulties with the structure of the duty roster, which presents particular problems in the afternoon. The “dependency” of residents for help from staff with personal care tasks such as moving around, washing, dressing, eating and using the toilet needs to be looked at in more detail so that the management team can be confident there are sufficient staff on duty at all times to meet the full range of care needs of residents. The checks made on staff who the management team proposes to employ need to be more rigorous and thorough, before staff start work at the home, to enhance the safety and welfare of vulnerable residents. Staff need to be properly supervised to ensure that standards are maintained and improved. The management team has a responsibility to consult with residents about their views on the quality of the service, and to audit and monitor this so that issues are identified and address promptly and the service continues to improve. Similarly, there is a need to audit the records that are held at the home to ensure that these meet with legal requirements and contribute to the overall quality and safety of the service. There are some health and safety issues needing to be addressed to ensure the requirements of other agencies, such as for fire safety are fully addressed (although progress has been made). The new management team have also identified shortfalls in records meaning that they do not have evidence that wiring and gas systems have been tested recently. 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. Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. The current manager states that no one will move into the home without proper assessment in future. The home does not offer a dedicated service for rehabilitating people so they can return home. EVIDENCE: The home has changed ownership, with a new registered provider and new registered manager, in August. No residents have been admitted to the home since this date and so it is difficult to assess the way in which this process is now managed, although the manager had a good record in this area at her previous place of work. The outcome of this standard has not therefore been “scored” at the end of the report. However, it is noted that there is an improved care planning system, awaiting introduction in the very near future, providing for a fuller range of assessment of need. Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 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): 10 Some people do not feel that their privacy is respected at all times. EVIDENCE: Of the five residents responding, three feel that their privacy is respected. One feels that it is not, and one that it is sometimes respected. Discussion with another resident indicated that the person felt sometimes staff would rearrange belongings they had no reason to access, without permission. Some shared toilet and bathing facilities do not have privacy locks and bedrooms are not all fitted with these. Staff were heard knocking on doors before entering rooms and those spoken to showed a respect for residents in their care. Staff were also noticed to speak politely and respectfully when conversing with residents. Two visiting health professionals say that they are able to visit their patients in private, and a resident confirms this. At the start of the hand over process, the door to the room being used was open and one staff member was asked whether they wanted the door shut,
Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 11 replying “if you like”. This did not reflect the closing of the door as routine practice when it is needed if confidentiality if not to be breached. Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 12 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 Residents do not all yet feel that the lifestyle they experience meets their social and recreational needs. Residents are able to maintain contact with family and friends. Residents would welcome more help to exercise choice and control over their own lives. There is room for improvement in the provision of a wholesome diet in pleasing surroundings. EVIDENCE: Half of the residents completing comment cards say that suitable activities are not always provided. Staff agree that they have little time, especially in the afternoon, to spend time with residents either individually or in organising group activities. One resident spoken to specifically commented that there were not many activities, nothing organised in the lounge, and that apart from religious services about twice a month there was not much else at all. However, one person had clearly enjoyed the organised outings during the summer.
Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 13 The care plans have undergone major review and restructuring and a new system will be launched in the very near future according to the manager. It was not therefore possible to assess the rigour with which social and recreational needs are assessed and addressed at this time. During the course of the inspection, relatives and friends were noted as coming and going freely. Residents confirm that they have visits and are able to receive people in their own rooms in private. One relative responding confirms being welcomed in the home at any time. Two residents completing comment cards say that they would like to be more involved in decision making in the home. Other residents spoken to did not express any concern in this area. Two out of five residents completing comment cards say that they do not like the food. One of these people was spoken to and commented that the food is not as imaginative as it has been previously. An anonymous complaint from a staff member indicated that residents did not like the food and that a lot of it was being wasted because it would not be eaten. The manager agreed that the new cook had taken some time to adjust to the food that residents liked and would eat and that some more work is needed in this area. It was noted that three of the residents spoken to say that the food is good and that they have enough of it. There are lists showing that people are asked about choices of meals. However, one person with some difficulties swallowing comments that this often restricts the choice available to them and that they often do not eat and drink well as a result. Elements of an anonymous complaint concern food hygiene and kitchen cleanliness confirmed in discussion with other staff. This affects the provision of “wholesome” food. This was an announced inspection and there were minor concerns only, although there are issues about lack of clarity on the cleaning schedules regarding frequency with which tasks should be completed. Additionally, the condition of the flooring makes it difficult to keep clean – there is some damage and there is staining in parts. The manager says that the owner has plans for some refurbishment. The dining room is not of an adequate size to seat all residents, although there is an additional area and the library which could be used. Some residents eat in their own rooms. Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 14 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 and 18 There is room for improvement in assuring residents and their representatives that their complaints will be listened to and acted upon. Residents are protected from abuse. EVIDENCE: The home has changed hands and therefore the complaints procedure has needed to be revised. The manager has completed this but it has not yet been given to residents and their representatives. Two out of three relatives responding did not know what the complaints procedure is. Two comment cards from residents, submitted anonymously say that those completing them did not know who to speak to if they had concerns. The remainder are clear and those people spoke to say that they do not have any complaints. However, one person commented that it would be nice to see more of the manager and for her to be “more available” to pop round and say hello to the people living in the home. The manager acknowledges that the inherited difficulties at the home have meant she has not been able to spend as much time “on the floor” and working directly with residents and staff as she would have liked and means to do so in the future. Staff spoken to are aware of issues that may constitute abuse, and of their responsibility to raise these promptly with the management of the home. The manager has clear expectations in this regard. Residents speak of staff as being very kind and caring and all of them spoken to or completing comment cards feel “safe” at the home. One relative comments that staff have been “re-enthused” under the new owner and manager, and one that the resident
Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 15 they visit is well cared for by friendly staff “in whom we have every confidence.” Comment has been made elsewhere about shortfalls in checks made on new staff. Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 16 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 and 26 There have been improvements in the maintenance of the environment although further work is necessary. The home was clean and hygienic at inspection (although see also standard 15). EVIDENCE: The new owners have undertaken some redecoration of rooms and have further work planned. This has included the replacement of a stair carpet that presented significant concerns for the safety of residents if they are able to use the stairs, and to staff. There are some shortcomings of which the manager is aware and which, given the nature of the investment required, she says will be addressed over a period of time. Further work is needed to comply with the requirements of the fire safety officer. See also standard 38.
Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 17 Given that the new owner and manager were only registered to operate the home in August and took over the home with significant shortcomings in a range of areas that they have had to prioritise, requirement has not been made at this time. Areas of the home seen were clean, although there were some difficulties in the kitchen area reported by staff in person and anonymously. These have been referred to environmental health. The person responsible for laundering clothes had information about additional precautions that would be necessary in the event of an infection, including MRSA, and information given was consistent with that of care staff. Care staff were able to clearly state the additional precautions they would take to avoid the risk of spread of infection and say they have appropriate protective clothing. They would welcome the provision of an extra sling for hoisting where these are restricted for use only with people who have an infection. The laundry is located in an outbuilding to the rear of the home, accessed via a covered walkway. Linen does not need to be taken through areas where food is prepared or eaten. There are sluice cycles available for soiled linen. The member of staff responsible for the laundry considers that the existing machines are adequate for the amount of laundry done in house. Sheets are sent away for washing. The laundry itself, although in use, was kept clean and tidy. Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 18 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, 29 and 30 Residents’ needs are met on most occasions by the numbers of staff, although there remain some problems. Residents are not protected by recruitment procedures and practices. There is room for improvement in assessment of training and competence of staff. EVIDENCE: There have been improvements in staffing levels since the new owner and manager took over the home. However, the shift pattern does create difficulties. There have been occasions, particularly during the afternoon, when staffing levels have fallen below the minimum expected levels. Sickness at short notice is still reported to present concerns. The manager and owner are actively reviewing how these issues will be addressed and are reminded that, where staffing levels fall below the minimum specified this affects the welfare of residents and must be notified to the Commission. The dependency levels recorded on the questionnaire completed by the manager, relate only to dependency for nursing needs, and do not take into account the assistance needed with personal and social care. Based on discussions with the manager, staff and observation, overall dependency levels are considerably higher than recorded on the questionnaire. One of the relatives responding considers that staffing levels have improved under the new management, but two thirds completing comment cards do not consider that staffing levels are always adequate. The new management have indicated
Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 19 their commitment to maintain staffing levels above the minimum levels stated in the historic staffing notice for the home. An anonymous complaint says that the manager and her deputy were away on holiday at the same time and that emergency support to the home was compromised. The manager agrees this had happened due to prearranged commitments before the home was taken over and the deputy manager assumed her post. However, the manager says that senior staff had contact details for both the owner and the manager of another home who would have provided support and advice if needed in an emergency. The situation will be avoided in future, so that staff providing advice and out of hours support are familiar with the home, the staff and the needs of the residents. Records of staff recruited during the summer, predominantly nursing staff, were seen. These do not reflect an adequate checking process before staff start work. Start dates show that checks against the Protection of Vulnerable Adults register are not obtained before all staff start work. There is not, in all cases, clear written explanation of why staff left previous “caring” posts, and in one case a referee was no longer employed by the organisation in which the person had last worked. Not all files contain proof of the person’s identity. The manager states that staff without the relevant checks do not work unsupervised. However, arrangements do not accord with guidance from the Department of Health regarding the Protection of Vulnerable Adults. Discussion with staff show that they have a good understanding of their roles. However, there was little evidence on staff files of rigorous induction and foundation, with assessment of competence. Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 20 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, 33, 36, 37, 38 Residents live in a home run and managed by people fit to be in charge. Improvements are needed to show that the home is run in the best interests of service users. Staff are not appropriately supervised. There are shortfalls in records needed to ensure residents are fully safeguarded. The promotion and protection of residents and staff health, safety and welfare needs some improvement. EVIDENCE: The owner of the home has successfully operated another home in the county for 25 years. The registered manager of Walcot Hall was formerly the manager of that home. She is a qualified nurse with extensive management
Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 21 experience and has been registered with the Commission. Although offering support as “consultants” to the former owners, they were not legally in a position to effect change and assume full responsibility for the operation of the home until August. There is, as yet, no formal process for monitoring and improving the quality of the service at the home, although there are informal checks and some audits (for example of medication). There has been some progress towards the process of monitoring the service for the provider, utilising a manager from another home, although this is not yet happening as set out in regulations with reports available to the Commission. However, residents spoken to say that they are well cared for but one commented that the manager needed to be more accessible. The manager says she has not yet been able to implement formal systems of regular supervision for all staff. Comment has been made elsewhere regarding the shortfalls in staffing records. The manager has also identified other shortfalls arising from poor record keeping in the past but is attempting to address these. The record of visitors to the home has been removed. The manager is reminded for the second time that this is a statutory record. The manager has identified shortfalls in evidence retained by the previous owners, that appliances and systems have been serviced with sufficient frequency and to ensure that they remain safe in use. This includes the heating and cooking appliances, and the electrical system. There are some issues outstanding from the fire safety officer’s visit, although the manager reports these are in hand. Additionally, no risk assessment for fire safety in the home could be produced and there are no overall risk assessments for activities and tasks undertaken around the home, including by ancillary staff. Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 22 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 X x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x x 1 1 2 Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? See summary 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 OP10 Regulation 12(4) Requirement The registered persons must ensure that arrangements for respecting residents’ privacy, both in terms of the provision of locks and the increased awareness of staff, are reviewed. The registered persons must ensure that residents’ social, and recreational needs are assessed and met. The registered persons must ensure that the advice of environmental health is sought regarding food hygiene and food safety measures at the home. The registered persons must ensure that there is a clear, up to date and accessible complaints procedure available and provided to residents and/or their representatives. The registered persons must ensure that the Commission is notified when staffing levels fall below expected levels. The registered persons must ensure that overall dependency levels are assessed and taken into account to determine the
DS0000065021.V256264.R01.S.doc Timescale for action 31/12/05 2 OP12 14, 15, 16(2) 23(5) 30/01/06 3 OP15 31/12/05 4 OP16 22 30/01/06 5 OP27 37 and 18 31/12/05 6 OP27 18(1) 30/01/06 Walcot Hall Version 5.0 Page 24 7 OP29 19, 13(6) 8 OP29 19, Sch 2 9 OP33 26 10 OP33 24 11 OP36 18(2) 12 OP37 17(2), Sch 4:17 23(4) 13 OP38 balance between nursing and care staff and to ensure both are adequate to meet needs. The registered persons must ensure that proper checks on staff are made before they start work at the home. The registered persons must ensure that records required by law in relation to each person working at the home, are held (taking into account amendments made to the schedule of records needed in July 2004) The registered persons must ensure that visits on behalf of the registered provider are conducted as set out in regulations with copies of reports supplied to the Commission. The registered persons must establish and implement a system for monitoring and improving the quality of the service with copies of associated reports supplied to the Commission. The registered persons must establish and implement a system for supervising all staff in accordance with national minimum standards. The registered persons must maintain a record of all visitors to the care home, including their names. The registered persons must ensure that action is taken as required by the fire safety officer. 31/12/05 31/12/05 31/12/05 28/02/06 28/02/06 31/12/05 31/12/05 Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP15 OP16 OP19 OP37 OP38 Good Practice Recommendations The registered persons should ensure that, in the light of a complaint and discussion with residents, the menus are reviewed and discussed with them and the catering staff. The registered persons should consider how they can improve their accessibility to residents on a more regular basis. The registered persons should provide the Commission with a schedule of works identified as necessary for improving the premises, with anticipated timescales. The registered persons should arrange for an audit of all records required by regulations and schedules, to identify and address shortfalls. The registered persons should arrange for an audit of records, risk assessments, service agreements and written guidance associated with the management of health and safety, to identify and address shortfalls. Walcot Hall DS0000065021.V256264.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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