Inspection on 04/11/04 for Wantsum Lodge

Care Home For Older PeopleWantsum Lodge32 St Mildreds Road Ramsgate Kent CT11 0EFAnnounced Inspection4th November 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Wantsum Lodge Address Wantsum Lodge, 32 St Mildreds Road, Ramsgate, Kent, CT11 0EF Email address Name of Registered Provider(s)/company (if applicable) Choicecare 2000 Limited Name of Registered Manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 32 Tel No: 01843 582666 Fax No:Category(ies) of registration, with (number of places) Old age, not falling within any other category (32) Registration number H050000665 Date first registeredDate of latest registration certificate 15th April 2003Was the Home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionIf Yes refer to Part CWantsum LodgePage 1 Date of inspection visit Time of inspection visit Name of Inspector Name of Inspector Name of Inspector 1 2 34th November 2004 9.30 am Brenda PearsID Code096658Name of Inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionWantsum LodgePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementWantsum LodgePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Wantsum Lodge. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Wantsum LodgePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Wantsum Lodge provides residential care to up to 32 older people, the Home is attached to a large building providing accommodation for the elderly and accesses Wantsum Lodge for catering and laundry services. The Home is situated in a residential area in the coastal town of Ramsgate, within easy walking distance of shops, post office and churches, and within a short drive of the town centre with community facilities such as health centres, library, railway station and a shopping centre.Wantsum LodgePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the Inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Externally, the Home is much improved now a maintenance/gardening person has been appointed. The grounds were tidy and enhance both the front and rear of the building. A new entrance area is being developed and new flooring is to be laid. Wansum Lodge provides a relaxed and friendly Home with Service Users enjoying a sing-a-long and dance during this inspection. The Inspector was pleased to speak to Service Users at this time who confirmed they are well cared for, happy and are supported to make choices. A recent evening had been enjoyed to celebrate Halloween and everyone stated this was a good evening. Family and friends are invited to enjoy celebrations. The Inspector was informed that the support from family and friends is much appreciated with some recent fundraising events giving the opportunity of acquiringWantsum LodgePage 6 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Wantsum LodgePage 7 Wantsum LodgePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 4&5 OP1OP1 Statement of Purpose & Service User Guide to be completed as stated in this standard and at schedule 1. That the storage of controlled drugs complies fully with requirements set by the Department of Health under the Administration & Control of Medicines in Care Homes 31/03/05213OP931/01/05312 & 17OP18Local procedures are developed for the Home Plan of to support staff at all times and for use during action due the induction process. 31/01/05RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the Registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard *Wantsum LodgePage 9 * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Wantsum LodgePage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with Service Users Individual discussion with Service Users Group discussion with staff Individual discussion with staff Discussion with management Service User survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of Service Users spoken to at time of inspection Number of relatives/significant others the Inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding Managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES YES YES NO YES YES YES NO YES YES YES NO YES NO YES NO 8 0 23 YES YES YES YES 17 0 04/11/04 9:30 8.0Wantsum LodgePage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care Homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Wantsum LodgePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to Service Users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the Home; and provides a Service Users guide to the Home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a Home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the Homes Service Users guide. Range of fees charged From (£) X To (£) XAny charges for extras If yes, please state what the extras are: Key findings/EvidenceYES Standard met? 2Both the Statement of Purpose and the Service User Guide have been produced but these documents require a great deal of additional information. Both documents must be produced in line with the guidance set out in Schedule 1 of the National Minimum Standards. The Manager stated both these documents would be reviewed.Wantsum LodgePage 13 Standard 2 (2.1 ­ 2.2) Each Service User is provided with a statement of terms and conditions at the point of moving into the Home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met?Standard 3 (3.1 ­ 3.5) New Service Users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective Service User, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The Inspector was shown written pre-admission assessments which have been undertaken to assess individual needs and to ensure the Home is the best place to meet those needs. The assessment includes physical and social needs and may be carried out in conjunction with health or social services professionals. Individual care plans were seen to have been prepared on admission based on these assessmentsStandard 4 (4.1 - 4.4) The registered person is able to demonstrate the Homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the Home. 0 Key findings/Evidence Standard met?Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective Service Users are invited to visit the Home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met?Wantsum LodgePage 14 Standard 6 (6.1 - 6.5) Where Service Users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable Service Users to return Home. 0 Key findings/Evidence Standard met?Wantsum LodgePage 15 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The Service Users health, personal and social care needs are set out in an individual plan of care. Service Users make decisions about their lives with assistance as needed. Service Users, where appropriate, are responsible for their own medication, and are protected by the Homes 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.Standard 7 (7.1 ­ 7.6) A Service User plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each Service User and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The Inspector was informed that care plans have been reviewed by the current Acting Manager. A sampling of care plans undertaken at this time evidenced full assessment of needs is undertaken and these are reviewed monthly. Records sampled were seen to be full, clearly recorded and current.Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains Service Users health and ensures access to health care services to meet assessed needs. No. of incidents where Service Users have been taken to Accident and Emergency during last 12 months No. of Service Users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence 23 0 Standard met? 3Records sampled at this time evidenced access to health professionals as appropriate, with full recording of any change in medication. The Inspector was informed that verbal adjustments are not accepted and all changes are supported by appropriate signatures. CPN, GP and care Manager visits, consultation and telephone calls are all clearly recorded on care plans. Continued cases of falls and incidents are reviewed by the Acting Manger on a monthly basis and clear recording was evidenced of night monitoring that shows when sleeping, waking, taken drinks, eaten and activities.Wantsum LodgePage 16 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and Service Users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? Medication is stored appropriately, fridge temperatures are taken and recorded regularly and battles were evidenced to be dated at the time of opening. Records sampled at this time were clear and current and contained photographs of each Service User. While there is a separate cupboard for the storage of controlled drugs, this needs to be bolted to the wall to comply with current requirements. The Acting Manager stated this would be undertaken.Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that Service Users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? The Service Users care plans were seen to refer to individual needs and wishes with regard to personal care. Staff confirmed that Service Users meet with health or social care professionals in the privacy of their own room. Staff confirmed that bedrooms are respected as private space and the Inspectors observed staff undertaking duties in an appropriate and considerate way at this time. Discussions at this time and questionnaires received prior to this inspection confirm that friends and relatives are always made welcome and offered refreshments. The Inspector was pleased to speak to Service Users at this time who confirmed they are well cared for, happy and are supported to make choices. A recent evening had been enjoyed to celebrate Halloween and everyone stated this was a good evening. Family and friends were also invited to enjoy the celebrations. Standard 11 (11.1 ­ 11.12). Care and comfort are given to Service Users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met?Wantsum LodgePage 17 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit Service Users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? Discussions with Service Users at this time and questionnaires received prior to this inspection confirm that routines are flexible and that individuals have a choice with regard to how the day is spent. It was also confirmed that routines are flexible particularly with regard to getting up and going to bed. Support is given to continue friendships with people outside the Home and visitors are made welcome. Connections with family and friends are strengthened through various celebrations and activities with everyone taking part.Standard 13 (13.1 ­ 13.6) Service Users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with Service Users preferences. 3 Key findings/Evidence Standard met? Several residents spoken to at this time confirmed they have visitors at any reasonable time and that their visitors are always made welcome. There are several lounge areas that can accommodate visitors and provide a meeting place for family and visitors. The Inspector was informed of a local event undertaken by family and friends that has been held to raise funds for equipment to be purchased. This event was very successful and the new equipment will provide additional entertainment in the Home.Wantsum LodgePage 18 Standard 14 (14.1 ­ 14.5) The registered person conducts the Home so as to maximise Service Users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? The Inspector observed on a tour of the building, that Service Users are given choices and decide how the day will be spent. This was also confirmed through conversations undertaken with Service Users at the time of this inspection and through the questionnaires received.Standard 15 (15.1 ­ 15.9) The registered person ensures that Service Users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The Inspector observed lunch at this time that looked and smelt appetising. Meals can be taken in rooms but encouragement is given to come to the dining room to socialise. The atmosphere during lunchtime was relaxed and unhurried, with a variety of meals being served. Snacks and hot drinks are also available anytime during the day or night as required, this was confirmed by Service Users spoken to at this time. Service Users stated they enjoy the meals and choices are given and alternatives provided as required. Tables have matching tablecloths and serviettes that also enhance the dinging area.Wantsum LodgePage 19 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the Home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence 3 0 0 3 0 0 100 3Standard met?There is a complaints policy clearly displayed and the Inspector was informed that there is a good relationship between family members and the Home that helps to keep channels of communication open. The Inspector observed family members openly approaching the Acting Manger at this time. Questionnaires received prior to this inspection also confirm family and friends are comfortable and enabled to address any matters concerning them.Wantsum LodgePage 20 Standard 17 (17.1 ­ 17.3) Service Users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met?Standard 18 (18.1 ­ 18.6) The registered person ensures that Service Users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The Home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence Standard met? YES 0 2Some discussion was undertaken regarding the policies and procedures currently in place. . Although these are described as `policies and procedures there are only policies in place. There is a need for local procedures to be developed that would fully reflect routines currently undertaken in the Home. These would then support staff in all areas and fully inform new staff through the induction period. This is specifically required for use when dealing with any case of abuse. Clear and specific guidelines are required to ensure correct actions are taken by staff at all times. Money is retained in the safe on behalf of Service Users, all records and receipts are retained with two signatures being recorded at each transaction.Wantsum LodgePage 21 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the Home is suitable for its stated purpose; it is accessible, safe and well maintained; meets Service Users individual and collective needs in a comfortable and Homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? Externally, the Home is much improved now a maintenance/gardening person has been appointed. The grounds were tidy and enhance both the front and rear of the building. A new entrance area is being developed and new flooring is to be laid. A shaft lift is available and appropriate safety measures are in place to protect Service Users. Redecoration and new carpets have enhanced the atmosphere is the Home. The Inspector also recognises the efforts and work of staff to ensure old carpeting is constantly washed and cleaned to maintain an odour free and clean environment.Standard 20. (20.1 ­ 20.7) In all newly built Homes and first time registrations the Home provides sitting, recreational and dining space (referred to collectively as communal space) apart from Service Users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each Service User. 3 Key findings/Evidence Standard met? The Home has various lounge areas and a separate dining room, these areas provide the required communal space. The Inspector was present in one lounge are enjoyed conversation and singing with those in this area at this time. All external spaces are easily accessible to wheelchair users.Wantsum LodgePage 22 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of Service Users. 0 Key findings/Evidence Standard met?Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of Service Users. 0 Key findings/Evidence Standard met?Wantsum LodgePage 23 Standard 23 (23.1 ­ 23.11) The Home provides accommodation for each Service User which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing Homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence NO YES NO X X X X Standard met? 0 X XX X X XWantsum LodgePage 24 Standard 24 (24.1 ­ 24.8) The Home provides private accommodation for each Service User which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the Service User. 0 Key findings/Evidence Standard met?Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of Service Users accommodation meet the relevant environmental health and safety requirements and the needs of individual Service Users. 0 Key findings/Evidence Standard met?Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? As previously stated, the Home is much improved through the new carpeting that is in some areas and through the continued vigilance and hard work of the care staff to keep floors clean. Pump soap and paper towels are in use and COSHH items were appropriately stored. All radiators are covered and wardrobes are secured to walls. Doors are alarmed, fire points are clearly signed as are all fires escapes.Wantsum LodgePage 25 StaffingThe intended outcomes for the following set of standards are: · · · · 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 Homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the Service Users, the size, the layout and purpose of the Home, at all times. Number of staff /hours in respect of Service User needs based on guidance recommended by Department of Health. Personal Nursing Care No. Service Users High No. staff hours 2 60 X needs allocated No. Service Users Medium needs No. Service Users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence 19 10 540 No. staff hours allocated No. staff hours allocated No. of staff hours provided 380 100 514 X X X0 17 X Standard met? 3The Inspector was previously informed that six staff are on duty during the morning period and four staff during the afternoon period. The Acting Manager explained that she felt this supported the needs of the Service Users. At the time of this unannounced inspection, all Service Users were seen to be clean and appropriately dressed and conversations confirmed care needs are met.Wantsum LodgePage 26 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the Registered Manager and/or care Manager, and in care Homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence 7 12 Standard met? 2The Home continues to work towards fully achieving this standard.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of Service Users. 3 Key findings/Evidence Standard met? The Inspector was told that all recruitment procedures were uniform and a full induction programme is undertaken with staff signing at each stage. All checks have been undertaken for the entire current staff group regarding ID, CRB and the Inspector was told that all required pictures are to be on files. A sampling of files at this time evidenced that some files are fully complete and the Acting Manger is reviewing these.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the Home and meet the changing needs of Service Users. 3 Key findings/Evidence Standard met? The Inspector was informed there is an ongoing training and development programme in place and NVQ training is being undertaken at levels 2 and 3. The Manager is currently undertaking NVQ level 4 in management and care. There is an ongoing rolling programme for training in First Aid, Food Hygiene has been undertaken this year and Manual Handling is also booked.Wantsum LodgePage 27 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 Homes record keeping policies and procedures. The health, safety and welfare of Service Users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The Registered Manager is qualified, competent and experienced to run the Home and meet its stated purpose, aims and objectives. 0 Key findings/Evidence Standard met?Standard 32 (32.1 ­ 32.7) The Registered Manager ensures that the management approach of the Home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met?Wantsum LodgePage 28 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of Service Users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the Home. 3 Key findings/Evidence Standard met? The Inspector was informed that discussions were regularly undertaken with families and professionals for feedback. Leaflets are also available for visitors and families. Meetings with Service Users are regularly undertaken and are conducted at the request of Service Users themselves. The Inspector was informed there is constant contact with family and visitors to ensure lines of communication are open and all events are relayed reported to the next of kin. Some items acquired following requests from Service Users are some musical organs and a piano.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met?Standard 35 (35.1 ­ 35.6) The Registered Manager ensures that Service Users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the Service User. Number of Service Users subject to Power of Attorney processes Number of Service Users subject to Enduring Power of Attorney processes Number of Service Users subject to Guardianship Orders Key findings/Evidence Standard met? 3 X X XService Users are offered a locked area for valuables if they wish, doors to rooms can also be locked and keys issued. Some small amounts of money are retained on behalf of those wishing to do so and families liaise with the Manager to ensure money is available at all times. All receipts are retained and double signatures for every transaction.Wantsum LodgePage 29 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the Home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met?Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of Service Users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met?Standard 38 (38.1 ­ 38.9) The Registered Manager ensures so far as is reasonably practicable the health, safety and welfare of Service Users and staff. 3 Key findings/Evidence Standard met? Records show full health and safety risk assessments for all chemicals currently used by staff in the Home, staff stated they are fully supported and can approach the Manager regarding any issue including any whistle blowing matters. Records and observations evidenced that the well being of Service Users is considered and those spoken to at this time confirmed they are well cared for. All relevant training regarding health and safety of Service Users and practices within the Home is ongoing, such as moving and handling and fire safety. Records relating to health and safety, including the accident book were evidenced and seen to be up to date. All incidents are reported fully and promptly to the Commission for Social Care Inspection. All safety precautions such as locked areas, alarms on exits and COSHH items securely stored were in evidence at this inspection. Risk assessments for the environment are regularly undertaken and are reviewed as are care plans.Wantsum LodgePage 30 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceWantsum LodgePage 31 Lead Inspector Second Inspector Regulation Manager DateBrenda Pears William Wallace 21/12/2004Signature Brenda Pears Signature Signature William WallacePublic reports It should be noted that all CSCI inspection reports are public documents.Wantsum LodgePage 32 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 4th November 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleWantsum LodgePage 33 Action taken by the CSCI in response to provider comments: Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The Inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 18th January 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. D.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: No response at the time of Publication.Wantsum LodgePage 34 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of Wantsum Lodge confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Wantsum Lodge am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Wantsum LodgePage 35 Wantsum Lodge / 4th November 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000023619.V169122.R01© This report may only be used in its entirety. 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