Inspection on 20/11/07 for Ward House Nursing Home

This inspection was carried out on 20th November 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ward House Nursing Home 23/06/09

Ward House Nursing Home 28/04/09

Ward House Nursing Home 04/03/09

Ward House Nursing Home 30/06/08

Ward House Nursing Home 12/07/06

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Winton House

Newbeech House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Ward House Nursing Home Ward House Nursing Home 21 - 23 Alpine Road Ventnor Isle Of Wight PO38 1BT Lead Inspector Annie Kentfield Key Unannounced Inspection 20th November 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ward House Nursing Home Address Ward House Nursing Home 21 - 23 Alpine Road Ventnor Isle Of Wight PO38 1BT 01983 854122 01983 854410 matron.whl@btconnect.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ward House Limited Susan Doris Davies Care Home 23 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (23), of places Physical disability over 65 years of age (8) Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One person is accommodated in the (DE) category (under 65 years). This named person may continue to be accommodated. The home may accommodate up to five people aged 60 - 65 years of age within the above categories. 12th July 2006 Date of last inspection Brief Description of the Service: Ward House is a registered care home providing personal and nursing care for up to twenty-three older people. The home has been converted from two older terraced properties to make one home. Accommodation is provided in thirteen single and five twin rooms, some with en-suite facilities. The home provides pleasant and comfortable communal space and has an enclosed rear garden with extensive sea views. There is outdoor seating for residents to enjoy the garden and sea views in the warmer months of the year. Limited car parking space is available at the front of the home. The building is accessible and there is a passenger lift for residents to access the upper floors. Current fees are £100 per day for a single room and £95.00 per day for a double or shared room. The home was purchased by the current owners, Ward House Limited, in November 2005. The home is managed by the registered manager, Mrs Susan Davies. Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is a summary of all the information that we have received, or asked for, since the last inspection of the home in July 2006. This included: the Annual Quality Assurance Assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Surveys returned to us by people using the service; residents, relatives, staff, and health and social care professionals who visit the home. What the service has told us about things that have happened in the home, these are called ‘notifications’ and are a legal requirement, and the previous key inspection report. An unannounced visit to the home was carried out by Annie Kentfield Regulatory Inspector on 20th November 2007 from 11am to 6pm. During this visit we spoke to some of the residents either in the communal areas or in the privacy of their own rooms. We also spoke to some of the staff, the manager, and deputy manager, visited all areas of the home, and looked at a number of records including care plans, recruitment records, service user guide, staff meeting minutes, fire and environmental health reports, fire log book, accident records, staff training records, and the staff rota. What the service does well: What has improved since the last inspection? There have been some improvements to the home environment: • All bedrooms now have height adjustable beds • New flooring in the first floor WC Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 6 • Refurbished sluice room Medication procedures have improved to meet a previous requirement. The manager is now registered with the Commission and has completed the Registered Manager Award (National Vocational Qualification level 4). What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents, or their families, are provided with the information they need to make an informed choice about moving into the home. Residents’ care needs are fully assessed and they know that their needs will be met when they enter the home. Residents and their families are invited to visit the home before making a decision. The home does not provide intermediate or rehabilitative care. EVIDENCE: We looked at an up-to-date information leaflet about the home that is given to prospective residents and/or their representatives. When residents move into the home they or their representatives are given a contract that sets out the terms and conditions of the services to be provided. A copy of the Statement of Purpose/Residents’ Charter, and the home’s complaints procedure is also available. Residents and relatives who returned surveys confirmed that they Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 9 had received enough information about the home before moving in. We spoke to two residents who said they had visited the home and chose to live there because they liked the location, and they were very satisfied with the care provided. The home has a process of assessment that gathers all relevant information about prospective residents to ensure that the home can meet all of their care needs. The manager explained that they also try to gather as much personal and social information as possible so that the home can try and meet residents’ individual social, cultural and spiritual needs. Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8. 9, 10 and 11 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in the home have their health and personal care needs met with respect for privacy and dignity at all times. The systems for the administration of medication are safe and secure. Residents and their relatives can be confident that the home will provide end of life care, where appropriate, with sensitivity and respect. EVIDENCE: We looked at three individual care plans with the deputy manager, who is responsible for care plans and reviewing and updating care records. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each resident’s plan; they give a comprehensive overview of their health needs and act as an indicator of change in health requirements. We also noted comments received in the surveys and observed practice in the home that confirms a good level of satisfaction with the quality of care provided. One relative wrote “I work closely with the manager and staff with Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 11 regard to my relative’s needs.” Comments generally indicated that care is provided with respect for individual choices and preferences and with regard for privacy and dignity. “We are very happy with the quality of care”. “Staff are very attentive and cheerful and respond to patients’ needs”. One relative commented that they would like to see their relative receive more therapies and treatment to encourage mobility and one person would like more communication from the home about changes in the health care needs of their relative. Several surveys commented on the need for more care staff at particular times during the day and one relative wrote “the morning routine could be improved – sometimes my relative is left in bed for a long time and this distresses them”. This was discussed with the manager and deputy manager who explained that they have changed the staff daily work allocation to try and ensure that personal care is provided in the mornings at a time that suits the residents, as far as possible. Several relatives and staff expressed concern that occasionally some personal items of clothing are not always ironed after laundering, and that they should be in order to promote the home’s commitment to dignity and respect. This was discussed with the manager who is aware of the problem. The manager explained that she hopes to appoint a member of staff who will undertake the ironing each week and plans to ensure that the ironing service will improve. The manager confirmed that since the last inspection all the beds in the home are now height adjustable, this promotes safer working practice for both residents and staff. The manager also confirmed that pressure relieving mattresses and other equipment to prevent pressure sores is always available and supplied as appropriate. We looked at the procedures for the administration and dispensing of medicines for residents. At the last inspection we made a requirement for the home to ensure that medication administration records are always fully completed and up-to-date. The home was also required to ensure that medication records are fully completed with information about any known allergies. We found that these requirements have been met. However, when we looked at the medication records we found that medication had not been dispensed for one resident. It was explained that the resident had chosen to go out that day and would be offered the medication on their return. It would be good practice for this to be recorded on the medication administration sheet. The manager undertakes regular monitoring and review of all the medication records to ensure that they are properly completed, this ensures that residents are receiving the correct medication, at the right time, and as prescribed. The manager explained that the home uses an ‘end of life care pathway’ plan whenever appropriate. The home has sought out guidance and best practice support in end of life care for residents. Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 12 Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager and staff are aware of the benefits to residents when offering social and recreational activities suitable to individual interests and abilities, but this process could be improved. The home welcomes relatives and friends to visit residents in the home. Attention is given to providing wholesome and appealing meals for residents with lots of choice and consideration of special dietary requirements. EVIDENCE: We received lots of positive feedback from residents and relatives that the food served in the home is very good. One person wrote “good well balanced meals with plenty of fresh vegetables” and another person said that they have lunch in the home several times each week with their relative and found the meals to be “excellent”. We spoke to one of the cooks who explained that they aim to present meals that are attractive and appetising. Where residents need food to be liquidised, all parts of the meal are separately liquidised and served. Some of the residents receive their meals in their rooms with assistance from staff and some of the residents like to take their meals in the dining room. We observed that lunch in the dining room is a relaxed event and the tables are Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 14 attractively laid with tablecloths and napkins, flowers, tablemats etc. and water/juice is always available. The home does not have a dedicated activities organiser, however, there are some entertainment activities available if residents choose to take part; a musical entertainer visits the home each week and a local community organisation offers reminiscence activity. A high number of the residents are frail and dependent and do not use the communal rooms, because of this, the reminiscence sessions are offered to residents on an individual basis, in their rooms. Residents are also offered the services of a hairdresser who visits the home fortnightly. There is an opportunity for residents to receive Communion every other week if they wish to, with a volunteer visitor. Activities are planned for the Christmas holiday with carol singers from a local school and a party to which all residents, relatives and staff are invited. The manager explained that they have developed an activities resource for staff with information about the things that each resident likes to do. This is a positive move to give residents the opportunity to have some planned social contact and recreation and needs to be developed for the positive benefit of the residents. The barrier at the moment to developing the activities programme is that staff do not have enough time each day to allocate time for social and recreational activities with the residents. However, the activities that are arranged are clearly appreciated and seen to be very beneficial for residents because one relative wrote ““There are weekly entertainments, usually musical, and the staff have encouraged my relative to start knitting to maintain hand mobility. Once a week people come to encourage talking about memories/past events to keep the brain active”. The home has an amenity fund and has recently purchased an additional and portable TV and DVD player that can be taken into residents’ rooms. There is a selection of DVD’s in the sitting room. The home has also acquired two budgerigars that usually live in the sitting room, however, one resident is very fond of them and occasionally they can spend the day in the resident’s bedroom, as the cage is portable. Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home understands the need to have a complaints procedure and staff are aware of the procedures for protecting and safeguarding the residents. EVIDENCE: We have not received any complaints about the service and there have not been any referrals or concerns about the safety of the residents. The home has a policy and procedure in place with regard to safeguarding adults and the prevention of abuse. Training records show that staff have received a training session in the protection of vulnerable adults (POVA) and surveys confirmed that staff know what to do if they have any concerns about a residents’ safety or suspicion of abuse. Comments from residents and relatives confirmed an awareness of what to do in the event of a concern or complaint. (Reference is made to the home’s quality assurance systems in the ‘Management and Administration’ section of this report.) We found that recruitment procedures for new staff are thorough and this ensures that the safety and welfare of the residents is protected. It is the policy of the home that residents’ financial and legal affairs are dealt with by relatives or other formal/legal representatives, independent of the home. Any expenses incurred by residents (such as hairdressing or chiropody) are invoiced to the resident or their representative and receipts kept of any expenditure. Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22 and 26 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally the home is safe, comfortable and clean for the residents. There is an ongoing programme to maintain the building internally and externally including decoration and refurbishment. Specialist equipment to meet the needs of the residents is provided, however, bathing and shower facilities are limited. EVIDENCE: We looked at all areas of the home and it was clean and tidy and there were no unpleasant odours at all. The home was warmly heated and the manager confirmed that since the last inspection new central heating boilers have been installed. The home has also replaced the flooring in the first floor WC and redecorated the second floor sluice room. Most of the comments in the surveys said that the home is always clean and fresh; some comments suggested that some rooms needed a ‘deeper’ clean of walls and under furniture. In discussion with the manager she confirmed that there is a Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 17 programme to do this that is being overseen by the maintenance person, employed by the home. Comments from the surveys indicated that the home environment is found to be comfortable and “homely”, however, there were several comments suggesting that the home environment could be improved with some “redecoration” and “modernisation”. We spoke to some of the residents in the privacy of their own rooms and generally those residents were satisfied that the rooms provide the facilities needed. The rooms vary in size and some of the rooms that are shared have limited storage space. However, residents spoken to said that although more accessible storage space for clothes and belongings would be good – they were still happy with their room and the views of the sea. The manager explained that it is sometimes possible for residents to move to different rooms when they become vacant. There are procedures in place for maintaining good hygiene with hand washing facilities and anti-bacterial hand gel dispensers. Staff in the home confirmed that they are supplied with gloves and aprons as good practice. One issue arose as a concern from a number of staff – that there is a risk of cross infection because some staff have to work in both the laundry and the kitchen. This was discussed with the manager who said that she would be reviewing practice in the home to ensure that all working practice is safe for both staff and residents. The manager will consider taking advice from an infection control specialist on best practice. We observed that specialist equipment such as hoists; wheelchairs and mobility aids were being used in the home. Since the last inspection there have been several occasions when the lift has broken down and although it is regularly serviced, the home needs to review the continuing viability of the current lift. The lift is essential to the home to ensure that residents are able to move around the home when they want to with the assistance and access that the lift provides. The facilities for bathing or showering are limited, however, care records show that most of the residents prefer to receive all of their personal care in their own rooms. The home should review their bathing and shower facilities as part of their quality assurance process and monitor feedback from residents and relatives to ensure that bathrooms and showers are easily accessible to residents and provide appropriate assisted facilities if this is needed. The ground floor WC used by the residents is in need of some decoration and refurbishment. The cistern is in a poor state and there was a leak that needs attention. Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service are generally satisfied that the care they receive is good, but there are times when they may need to wait a short time for staff support and attention. The home is reliant on agency staff to cover shortfalls in the staffing rota due to absence, staff training or vacancies. EVIDENCE: We received lots of comments from relatives and residents praising the staff for their skills, commitment and friendly caring attitude, however, there were also a number of comments from relatives and staff that reflected their observations that on occasions the home is running with some staff shortages. This is evident because staff do not always have time to do social and recreational activities with residents, and there are times when residents have to wait for attention when staff are busy. It is evident from comments, care records, and our observations of practice, that staff in the home work very hard to meet all of the residents’ health and personal care needs. However, a large number of staff expressed concern about the difficulty of obtaining staff cover at short notice, particularly weekends. Continual staff shortage has the potential to place residents at risk of their care needs not being fully or consistently met at all times. There is also the risk that staff training and development needs may be overlooked if the home does not have consistent levels of staff and skill mix. This was discussed with the manager who had already highlighted staffing issues in the home’s Annual Quality Assurance Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 19 Assessment (AQAA). The manager has identified “staff recruitment and retention”, “long term staff sickness” and “lack of training availability” as barriers to improvement in the home over the last 12 months. The manager plans to address these concerns and review staffing and training issues with the registered owners of the home. The home operates thorough staff recruitment procedures to protect the safety and welfare of the residents. There is also a staff training programme to ensure safe working practice in the home. Some of the staff are about to begin a distance-learning course in dementia awareness and dementia care and there is a rolling programme to offer care staff the opportunity to complete the National Vocational Qualification in Care (NVQ), levels 2 and 3. There are systems in place for formal staff supervision and planned observation of practice, and staff meetings are held several times each year to discuss practice and staffing issues. Training updates are also provided for the registered nurses to maintain professional practice qualifications. New staff follow an initial in-house induction programme for one week before going on to complete the nationally agreed ‘common induction standards’ for care. Generally, comments from staff indicated that they would welcome greater training opportunities and would like to see a longer and more structured induction period for new care staff, particularly when newly recruited staff are new to working in the area of care. This would help to ensure that the staffing numbers and skill mix of qualified/unqualified staff are appropriate for the needs of the residents, the size, layout and purpose of the home, at all times. Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is qualified and experienced and the home is well managed and has a health and safety policy to meet all health and safety requirements and legislation. Residents’ financial interests are protected and their safety and welfare are safeguarded. However, more work is needed to develop a system of quality assurance that monitors and reflects how well the service is meeting the needs of the residents, what the home does well, and what improvements are needed to ensure compliance with the National Minimum Standards and Care Homes Regulations 2001. (This was a requirement from the inspection of 2006) EVIDENCE: We found evidence that the manager has systems in place to ensure that the home is meeting all health and safety requirements including fire safety and Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 21 food safety. A recent food safety inspection gave the home a four-star quality rating. The manager has commissioned a fire safety advisor to assess the home’s fire safety procedures and produce a fire risk assessment. The fire safety assessment identified some areas that require improvement/action and these are being addressed. The information that we requested from the manager confirms that the home has a waste disposal contract and regular service contracts for equipment and services in the home. The home must develop good systems for quality assurance that monitor and review how well the service is meeting the needs of the residents in the home. The manager has introduced a questionnaire that is given to some of the residents during their annual care review. However, the use of the questionnaire has been limited and the surveys do not include all stakeholders in the service (by stakeholders we mean residents and their representatives, relatives and visitors, staff, and health and social care professionals). An effective system for quality monitoring would give people an opportunity to feedback the positive outcomes for them and also provide constructive comments for the home to measure how well the service is meeting residents’ needs. A summary of the feedback received in the satisfaction questionnaires could be included in the home’s development plan. This was a requirement from the previous inspection: “The manager must consider how information gained from quality assurance work may be incorporated into an annual development plan for the home based on a systematic cycle of planning – action – review- reflecting the aims and outcomes for residents”, but this requirement has not been met within the timescale for action. The previous inspection also highlighted that the registered owners/care providers must undertake regular inspections of Ward House and prepare written reports on the standard of care provided in the home. We were told that a representative of the registered providers visits the home but there is no evidence of the home being inspected and a written report made, and this is a regulatory requirement. (Regulation 26 of the Care Homes Regulations 2001) The provider’s monthly inspections should also be part of the home’s continuing quality assurance to demonstrate that the service is meeting all regulatory requirements, and also demonstrate how well the service is providing good outcomes for people using the service. Inspection reports made by the provider do not have to be sent to us, but must be available for inspection when we visit. Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X 2 3 X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP33 Regulation 24 Requirement The home must have a system for reviewing and improving the quality of care provided at the care home. The system must include consultation with residents and their representatives. This is a repeat requirement and the previous timescale of 01/09/06 has not been met. 2. OP33 26 The registered provider or a representative must visit the home at least once a month and inspect the standard of care in the home and prepare a written report on the quality of care provided. 30/01/08 Timescale for action 30/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000065874.V349823.R01.S.doc Version 5.2 Page 24 Ward House Nursing Home Standard Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Ward House Nursing Home DS0000065874.V349823.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!