Inspection on 21/07/07 for Wallace House

This inspection was carried out on 21st July 2007.

CSCI found this care home to be providing an Adequate service.

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

Wallace House 29/02/08

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

CARE HOMES FOR OLDER PEOPLE Wallace House Ravensworth Road Dunston Gateshead Tyne & Wear NE11 9AE Lead Inspector Irene Bowater Unannounced Inspection 21st July 2008 09:45 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 Wallace House DS0000070994.V368776.R02.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. Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wallace House Address Ravensworth Road Dunston Gateshead Tyne & Wear NE11 9AE 0191 460 3031 0191 460 2996 wallacehouse@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross BC OpCo Ltd Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Manager post vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 40 The maximum number of service users who can be accommodated is: 40 29th February 2008 2. Date of last inspection Brief Description of the Service: Wallace House is a care home that provides permanent accommodation with personal care support and nursing care for up to a total of forty older people, some of whom may have a physical disability and / or sensory loss. The property is situated on a main thoroughfare in Dunston, and is within walking distance of a range of local amenities, including a health centre, pharmacy, shops, places of worship and public houses. The Metro Centre shopping complex is also only a short distance away. The area is well served by public transport. Accommodation is purpose built over two levels, each with facilities that include lounges, dining areas and bathrooms. All bedrooms are single with en-suite toilets and one room is suitable for sharing by a couple. Off road car parking is available at the rear and side of the home. At the front there is a small garden and patio area that can be reached from one lounge, which people may enjoy in good weather. The building can be easily accessed inside and out by people using wheelchairs. Fee rates vary from £394 to £449:50.The free nursing care element is set nationally. Items not covered by the fees include hairdressing, toiletries, newspapers, clothing and person items. Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. Before the visit: We looked at: • Information we have received since the last visit on 29 February 2008. • How the service dealt with any complaints and concerns since the last visit • Any changes to how the home is run • The provider’s view of how well they care for people • The views of people who use the service and their relatives, staff and other professionals The Visit: An unannounced visit was made on the 21 July 2008.This visit started at 09:45 and was completed at 16:00. During the visit we: • Talked with people who use the service, relatives, staff, the support managers and visitors. • Looked at information about the people who use the service and how well their needs are met. • Looked at other records, which must be kept. • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. • Looked around the building to make sure it was clean, safe and comfortable. • Checked what improvements had been made since the last visit. We told the support managers what we found. And wrote to the Responsible Individual about the lack of consistent management in the home. What the service does well: The staff collects information together about the person before anyone moves into the home to make sure they can meet their needs. Visitors are always welcomed and there are links with the local community. Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 6 The menus offer a variety of well-cooked nutritious meals. People can enjoy a healthy, well-balanced and interesting diet. People said: “We get beautiful dinners” “Excellent food” “Enjoy all of the food” Clear information is available should anyone have a concern or complaint about the care or service they are receiving. Staff are respectful and sensitive with people when helping them or when speaking to them. People said: “They are good” “I get help when I want” Three surveys were returned to the Commission from people living in the home. They said : “They usually received the care and support they needed” “They usually like the meals in the home ” “We would be able to make a complaint” The home makes sure that all checks and clearances are received before staff are employed. There are good arrangements for supporting people to keep their personal monies in a safe place if they want. The home is clean and kept free from any odours. What has improved since the last inspection? What they could do better: The recruitment of an experienced, effective manager is necessary to consistently improve and develop the service. Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 7 The staff need constant support so that they can feel confident that they will be able to meet people’s needs in a professional manner, taking the principles of a person centred approach to care into account Medicine cupboards, one trolley and the drug fridge need to be replaced. All information on the Medicine Administration Records needs to be written in plain English and abbreviations must not be used. An activities programme needs to be in place so that people can choose how to spend their leisure time. Surveys said: “The home should have more activities to stimulate X and the others” “Not enough activities” “Days could be more enjoyable with some kind of activity or entertainment” Start a programme of redecoration, re-carpeting and replacement of furniture communal areas and bathrooms, so that people live in a pleasant and safe environment. Review staffing levels at mealtimes so everyone can enjoy their meal at the point of service and they don’t have to wait until a member of staff is free to help them. A planned training and development programme needs to be available with details of all training recorded. The Company’s quality assurance system needs to be followed so that people receive consistent quality of care and their views are taken into account. In house maintenance checks must take place according to procedures and records of all checks must be kept. 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. Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 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 Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive clear information about the service and a comprehensive assessment of need before admission. This helps them make the right decision about using the service. EVIDENCE: The home has a Statement of Purpose and Service User Guide, which is readily available in the reception area. And each person is given a “mini service user guide”, which is kept in their room for easy access. Before moving into the home people have an assessment of need, which is completed by, care managers, nurse assessors and the home manager. Assessment tools include dependency levels, fall risks, moving and handling, pressure sore prevention, nutrition, and continence care. This information is Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 10 needed so that people can receive the correct level of care as soon as they are admitted. Information about previous lifestyles, current social preferences, ethnic origin and wishes at the end stage of life is now being completed. Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Access to health care is good and detailed care planning demonstrates that peoples’ needs are being fully met. EVIDENCE: Since the last visit to the home all of the care plans have been reviewed and updated. This is because some of the previous records did not show how staff were delivering nursing care. Staff complete pressure sore risk, dependency, moving and handling, nutritional assessments using the Malnutrition Universal Screening Tool (MUST), continence and fall risk assessments. These tools help the staff understand the level of risk each person and helps them complete a care plan. Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 12 Care plans showed that they are now fully completed, dated and signed. This means accurate information is always available. Risk assessments and evaluations of care are carried out at least monthly. Where people have been assessed as needing help with mobility the care plans specify the moving and handling techniques or the specialist equipment needed. Clear information is available about catheter care and how and when the catheter is to be changed. This makes sure that the risk of infection is reduced and all staff know how to care for that person. One person had been identified at having lost weight. Risk assessments are now in place to show how that person is being supported with eating and drinking. Weekly weights are recorded and the records show that this persons weight is starting to increase. Daily progress records are being completed in more detail regarding daily personal and health care. There are still some unclear records. For example, “settled day”, “needs attended” and “assistance give by two” do not show how staff are giving support and sometimes-complex nursing care to people. Information about people’s previous lifestyles and preferences are now being recorded. For example, staff record if anyone has preferences about having help with personal care by male or female carers, one person likes jigsaws and chair exercises and other plans show what peoples religious preferences are. Although this information is available, detailed social care plans are not. Everyone has access to all NHS facilities to ensure their healthcare needs are met. There are regular visits from GP’s and other health professionals including, dentists, opticians and chiropody services. Appropriate pressure relieving devices are available. Several people have air cell mattresses and cushions to prevent pressure damage. Advice is sought from, occupational therapists, tissue viability nurses, speech therapists and continence advisors. Visits from the multi disciplinary team are recorded in individual care plans. Medication policies and procedures are available for staff to use. The nursing staff are responsible for the safe administration of medicines to all of the people living in the home. Records are in place for all medicines received, administered and disposed of. An audit of Controlled Drugs and the Medicine Administration Records (M.A.R.) showed no discrepancies. Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 13 When staff are handwriting directions on the M.A.R. sheets they are using medical abbreviations such as T.D.S, O.D, and PRN. Staff need to write out all directions in clear, simple language that everyone can understand so that people receive their medicines at the correct time and dosage. One of the locks on the medicine trolley was broken but it was confirmed that another trolley was on order. The medicine storage cupboards are rusty with the paint coming off. This means they cannot be cleaned properly. A new drug fridge is on order and the one being used does not maintain the right temperature. Many of the staff have worked in the home for some time and know the people they care for well. All of the staff worked very hard to make sure everyone was treated with respect and their rights to privacy and dignity maintained. Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 14 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): 12,13,14,15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Opportunities to take part in meaningful activities and keep control of everyday decisions are limited, and mealtimes are not always well organised. This prevents people from leading full and active lives. EVIDENCE: The home still does not have an activities organiser. Staff try to organise activities for people in the afternoons. Evidence of how people are supported to spend their social and leisure time are recorded by a coding method in the care plans but this is difficult to follow and does not record why people have refused or do not want to join in events. During the day the main event was a visit from the hairdresser with little else happening. Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 15 Visitors are welcome at any time and are able to use the lounges or their relatives’ bedrooms for visits. It was confirmed that there are no restrictions regarding visiting times. Information about advocacy is available in the home. Many people have brought small items with them making their rooms homely and reflective of their previous lifestyles, religious beliefs or cultural backgrounds. There are dining rooms on each floor of the home. Should anyone want to eat their meals in their own rooms this service is readily provided. Since the last visit new dining room furniture has been provided and bins with lids have been ordered. The upstairs kitchenette has the vinyl flooring lifting, the worktop damaged, cupboard doors do not shut and the milk spillage in the fridge had not been cleaned up. Tables on both dining rooms are properly set for meals. This includes tablecloths, napkins, appropriate crockery, cutlery and condiments. Lunch choices were sausages and onions or pork casserole with potatoes, green beans and carrots. Alternatives would be available on request, such as sandwiches, salads or baked potatoes with fillings. Dessert choices were bread and butter pudding with custard, yoghurts and ice cream. The meal was nicely cooked, of good portion size and well presented. Plenty of drinks were offered including orange and cranberry juice. Many people on both floors need help with their meals. Meals were served and then some people had to wait for help and it was difficult for staff to make sure everyone had sufficient hot food at this time. Staff had to help more than one person at a time. This means people did not receive individualised care and the mealtime experience would not be enjoyable. It also means their choice is limited. Staff said this was a “very busy time” and sometimes “some people have to wait”. They assisted quietly and had a good understanding of individual needs. There were plenty of snack foods and drinks available throughout the day. Comments about the food included: “We get beautiful dinners” “Excellent food” “Enjoy all of the food” Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 16 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good complaints and protection procedures are in place. People can be sure that their views are always listened to and that they are protected from harm EVIDENCE: The Company has comprehensive complaints policy and procedure, which is available in the home. There have been four complaints made at home level since the last inspection. One has been resolved and one is being dealt with at home level. The Local Authority has raised one complaint and this is being dealt with by the Company. One concern was reported to the Commission for Social Care Inspection (CSCI) and this was returned to the Company to investigate. Clear Safeguarding Adults policies are available and staff were able to say what they would do should they be concerned about care practices. And staff complete safeguarding training which links into the Local Authority procedural framework. Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 17 There are currently no safeguarding referrals reported to CSCI or Local Authority. Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 18 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): 19,20,21, 22,24,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and safe but further investment is needed to create a more pleasing comfortable, place for people to live. EVIDENCE: The communal areas of the home are spread over two floors. Each floor has lounges, a dining room, bathrooms and toilets. Access to the small garden is through one of the lounges. This area faces straight on to the street and some screening needs to be considered so the people have a degree of privacy should they choose to sit in the garden. Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 19 Redecoration of communal areas has been completed since the last visit and new dining tables and chairs have been provided. The chairs in all of the lounges are now looking “tired” and marked from constant use. Carpets in both the dining rooms and lounges are ready for cleaning or replacing as they are marked from food debris and wear. The vinyl in the small kitchenette is lifting and the sink unit damaged. The previous smoking room carpet is covered in cigarette burns and the chairs are stained. There are bathrooms and toilets on each floor. The flooring in all areas is starting to look worn. Two baths, showers are out of use and quotes have been sent to have new ones fitted. This means there are not enough working bathrooms for all of the people living in the home. One room on the top floor was full of cardboard boxes, continence pads, and wood and Christmas decorations. The two supporting managers were made aware of potential risks and staff started to clear the room. The extractor fans in all areas are noisy and dusty. This means that air is not exchanged within areas such as en-suites and sluice rooms and this increases the risk of cross-infection. There are bedrooms on each floor and all have an en-suite facility. People have brought small items with them making their rooms homely and reflective of their lifestyles. The home has sufficient equipment with a number of modern, adjustable, beds with built in rails available. Alternative strategies were being employed to avoid the use of rails whenever possible. A loop system used to amplify sound for people using hearing aids, has been fitted in the lounge and is in working order. This means that people who use hearing aids can hear the TV/radio or a microphone if a residents’ meeting is held, while the volume is not too loud for people not using hearing aids. The laundry is very compact but is clean and organised. Liquid soap and paper towels are readily available for staff to use. Most of the areas do not have footoperated bins with lids to prevent spread of infection. On the day of the visit the home was clean and odour free. Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 20 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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and systems around recruitment, selection and training of staff are good and meet the range of needs of the people using the service and protect them from harm. EVIDENCE: The home has been without a registered manager for some considerable time. The newest manager started to work at the home in September 2007 until June 2008 when he was transferred to another home in the Company. On the day of the visit there were thirty-four people living in the home. There were two qualified nurses on duty supported by five carers. Overnight there is one qualified nurse and three care staff on duty. In addition there are domestics, laundry, cook, kitchen assistants, and an administrator. A maintenance person was recently employed but there is still a vacancy for an activities organiser. Staff rotas show that there have been shortages due to staff phoning in sick or being absent. There have been occasions where the staffing levels for care Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 21 staff have not been sufficient. The support managers are aware of the problem and have started to address the issues with the staff concerned. Dependency levels on both floors means that many need two staff to assist with all of their daily living needs. Staffing during mealtimes is not always sufficient to make sure that all of their needs are met on an individual basis. This is especially so when the nurse is called away at mealtimes or is busy with other things. Staff files showed that a suitable application form had been used. Two references are obtained and Criminal Records checks are always carried out before anyone is employed. Personal Identification Numbers (PIN) of qualified staff are checked with the Nursing and Midwifery Council to make sure staff are registered. The support managers confirmed that staff have completed training but records are not available to evidence either mandatory or specialist training. Training provided does include enteral feeding, care planning and documentation, Safeguarding Adults, tissue viability, Palliative Care, Dysphasia training with a lead nurse and carer being trained. Staff said they have completed infection control and health and safety training. Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 22 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): 31,32,33,35,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Without consistent management there is a lack of leadership and guidance, which means there is only adequate quality assurance systems in place and people may be placed at risk. EVIDENCE: The home has not had a registered manager for over a year. A manager was employed in September 2007 but was transferred to another home within the Company in June 2008. Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 23 Since then managers from different homes have been coming to work at the home for short spells. The constant changes in senior staff result in staff being unsure what is expected of them and then doing what they think is right. This means the focus is on the task, getting the job done without looking at the individual needs of those using the service. Following the site visit a letter was sent to the Responsible Individual requiring information about how the home is to be managed until a suitable manager can be appointed. Regular meetings with people living in the home and their representatives have taken place. But the last staff meeting was held in April 2008. Some quality assurance systems are being carried out. These include care plans, accident and pressure ulcer prevention. The AQQA had not been returned by the specified date or by the day of the site visit. It was found to be still on the computer waiting to be completed. Given the lack of consistent management a further extension was given. It had not been returned by the extended agreed date of the 4 August 2008. A telephone call to the home on the 5 August 2008 resulted in the AQQA being e-mailed to CSCI. It gave a reasonable picture of the service and information about how it plans to develop over the next year. The personal allowance records demonstrate that receipts and double signatures are maintained for all transactions. These could be cross-referenced and weekly checks are carried out to make sure there are no discrepancies. The home has also been without a maintenance person for some time. Records show that the required monthly and weekly checks for water temperatures; legionella, and nurse call system, emergency lighting and fire checks have not been completed from February 2008. This means people could be at risk from infection and health and safety risks. The newly employed maintenance person is working hard to bring all checks up to date. External maintenance contracts are up to date. Wallace House DS0000070994.V368776.R02.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 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 2 2 2 3 X 3 X 2 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 X X 2 Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement The registered persons must ensure that all directions on the Medicine Administration Records are written out in plain English and abbreviations must not be used. The registered persons must provide a second medicine trolley that can be locked. The metal storage cupboards and the medicine fridge must be replaced. The registered persons must review the organisation of mealtimes. The registered persons must replace the lounge chairs and carpets as part of the refurbishment plan The registered persons must replace the vinyl flooring and sink unit in the upstairs kitchenette. The registered persons must replace and repair the two broken baths/showers. The registered persons must ensure that all areas have suitable bins with lids. DS0000070994.V368776.R02.S.doc Timescale for action 01/09/08 2 OP9 13 01/09/08 3 4 OP15 OP19 12 16,23 01/09/08 01/01/09 5 OP20 16,23 01/10/08 6 7 OP21 OP26 23 13,16 01/09/08 01/09/08 Wallace House Version 5.2 Page 26 8 9 OP27 OP30 18,24 12,13,18 10 OP31 9,10,12,3 8 11 OP38 12,13,23 All extractor fans must be free from dust, noise and be in working order. The registered persons must ensure that there are enough staff deployed at mealtimes. The registered persons must ensure a planned training and development plan be produced and implemented with records kept. The registered person must ensure that an appropriately qualified experienced person is employed to manage the home. The Commission for Social Care Inspection must be informed of any temporary management arrangements in the home. The registered person must ensure that all maintenance and health and safety checks are carried out with records kept. 01/09/08 01/10/08 01/09/08 01/09/08 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 Refer to Standard OP7 OP12 Good Practice Recommendations Cease using abbreviations; vague terms and jargon within care plans and other documentation to avoid misunderstanding of information by staff. The registered person must ensure that people have more opportunities to be involved in varied and individualised social activities, which must be recorded in detail. Up to date information about activities must be provided and circulated in formats suited to their needs. The provision of seating and screening at the patio area should be considered. The registered persons must maintain systems of evaluating all aspects of the service and take the views of people using the service into account DS0000070994.V368776.R02.S.doc Version 5.2 Page 27 3 4 OP19 OP33 Wallace House Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Wallace House DS0000070994.V368776.R02.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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