CARE HOMES FOR OLDER PEOPLE
Warley House Warley Road Scunthorpe North Lincolnshire DN16 1PL Lead Inspector
Beverly Hill Unannounced Inspection 20th July 2006 09:00 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 Warley House DS0000002881.V295656.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. Warley House DS0000002881.V295656.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Warley House Address Warley Road Scunthorpe North Lincolnshire DN16 1PL 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) 01724 861507 Barton Medical Services Limited Tracey Anne Borrill Care Home 39 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (39) of places Warley House DS0000002881.V295656.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: Warley House is a Care Home providing personal care and accommodation for thirty-nine older people, twenty of whom may have a diagnosis of dementia. They provide a day care service for up to five people per day. The home is situated in a housing estate in Scunthorpe some distance from the town centre and local amenities, although on a local bus route. The building is of an old style and the home is currently undergoing a redecoration and refurbishment programme. There is an enclosed garden at the rear of the property and a separate house within the grounds, which has been developed into a laundry. Warley House consists of a two-storey building serviced by a passenger lift and stairs. The home has twenty-one single and nine shared bedrooms, none of which have en-suite facilities. The home has four sitting rooms and a large dining room. There is also a smaller quiet dining room on the upper floor but it tends to be used as a training room for staff. Just inside the main entrance is another smaller seating area, which is part of a thoroughfare but attracts some people, who want to sit and watch what goes on. The home also has a designated smoking room and a staff sleep-in flat. The home has five assisted bathrooms and sufficient toilets appropriately sited throughout the home for ease of access. According to information received from the home on 27.06.06 their weekly fees are £315 to £380. Items not included in the fee are toiletries, hairdressing and chiropody. Warley House DS0000002881.V295656.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over one day. Throughout the day the inspector spoke to eight service users and two relatives to gain a picture of what life was like for people who lived at Warley House. The inspector also had discussions with the manager, one senior carer and three carers. The inspector looked at assessments of need made before people were admitted to the home, and the home’s care plans to see how those needs were met while they were living there. Also examined were medication practices, activities provided, nutrition, complaints management, staffing levels, staff training, induction and supervision, how the home monitored the quality of the service it provided and how the home was managed overall. The inspector also checked with service users to make sure that privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured they were protected and safe in a clean environment. The inspector also observed the way staff spoke to service users and supported them, and checked out with them their understanding of how to maintain privacy, dignity and choice. The inspector took out a selection of surveys for service users, family members, staff members and professional visitors to the home to complete. There were very few surveys returned. Two staff members stated that they had positive support from the manager and felt the food was good and people were well looked after. What the service does well:
The home continues to have a low staff turnover. This meant that staff had worked at the home for a long time and knew the people who lived there well. The home had enough staff on duty at each shift. People spoken to said the staff team were very good, were friendly and helpful. One relative stated, ‘from the cleaner to the top person the staff are very good, the care is 101 ’. People said staff always knocked on doors before going in to their bedrooms and always respected their privacy. The home was well managed and the staff team showed genuine affection for the people they supported. The home looked after people with quite complex needs especially those with dementia and the staff made sure that the care plans they completed included all the service users needs that had been identified at the assessment. Staff received regular supervision and there was a training plan to ensure staff had the necessary skills to support older people. Warley House DS0000002881.V295656.R01.S.doc Version 5.2 Page 6 The home had a friendly and homely feel and there were lots of different areas for people to sit. Visitors were welcomed at any time of the day and this was confirmed in discussions with relatives the inspector met on the day. It had a large dining area to accommodate everyone and was generally clean and tidy although the carpet near the dining room and up both sets of stairs was in need of cleaning or replacement. People who lived at the home stated they liked the meals and drinks provided. They said they had plenty to eat and they always had choices at each meal with fresh fruit and vegetables. The home was reassessed for the Local Authority Gold Standard Award for quality monitoring in May 2005 and had been successful. What has improved since the last inspection?
The manager had tried to complete all the things the inspector had asked her to do at the last inspection and a maintenance plan was completed. Some things had still not been completed such as improvements in the general environment but it was recognised that this did take time. All the sinks in the bedrooms had now been boxed in so redecoration could begin. Three bedrooms had been redecorated and two of these were awaiting new carpets. The foyer had been decorated and re-carpeted and looked much better and two new chairs had been bought for service users. New curtains had been purchased for some rooms and the ones that had been redecorated were a big improvement. The garden area at the front and rear of the building had been cleared and tidied. The staff members were now able to monitor service users’ weight for those unable to stand, as the home had purchased sitting scales. This was important as staff needed to make sure that weight did not fluctuate too much and professional advice was sought if there was a consistent loss in weight. At the last inspection one bedroom only had net curtains as the drapes had been pulled down. The manager had sorted this out and replaced the curtains. She had also made sure that those service users who needed a lockable facility for personal items or medication had one in place and bedroom doors had privacy locks, which several service users made use of. A training plan for staff was in place and the manager kept a log of who had participated in training and the date this took place. Since the last inspection the amount of care staff that had completed specific training in the care of older people (National Vocational Qualification Level 2 in care) had increased and they now met the target of over 50 of the care staff team trained to this level. This was important, as the staff team need to have the necessary skills to support older people.
Warley House DS0000002881.V295656.R01.S.doc Version 5.2 Page 7 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.
Warley House DS0000002881.V295656.R01.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 Warley House DS0000002881.V295656.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. EVIDENCE: Four case files were examined one of which was a new admission. All had assessments of need completed prior to admission usually by care management as well as by the home. The new admission had an assessment prior to entering the home from hospital. Assessments cover all aspects of health and social care. The assessments were completed by the manager or senior carer. On the day of inspection the senior carer visited a prospective service user in hospital to complete an assessment. One case file indicated that the assessment and susequent care plan addressed issues of diversity with very clear routines and likes and dislikes established and when checked later these were followed through in practice. Warley House DS0000002881.V295656.R01.S.doc Version 5.2 Page 10 Staff members discussed how they supported the new service user to settle in during the admission process. We show them to their room, unpack and make sure they have their things around them, We reassure them as it can be a big shock coming into a home, and you have to respect people if they dont want to mix, its got to be at their own pace. Case files had copies of letters sent to the service user or their representative stating the homes capasity to meet needs. The homes statement of purpose refers to trial visits and there was evidence of day care and respite services in order for the service user to be introduced into the home. Warley House DS0000002881.V295656.R01.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 at least once during a 12 month period. 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. Service users health and social care needs are planned for and met and although a care plan for one service user had not been formulated after her very recent admission, staff were collating information about their rapidly changing needs and were fully aware of the tasks they were required to complete to meet them. The home supports people who are dying in a caring and appropriate way. EVIDENCE: Three care plans were examined and two of these were comprehensive and individualised focussing on specific needs with clear tasks for staff. There was evidence that they had been updated when needs changed and were evaluated monthly. There was also evidence that senior staff had audited the care plans and left instructions to key workers to complete certain tasks, which were then completed. Care plans reflected information in the assessments and highlighted areas in which the service user was independent and areas where professional support was needed. A third had not been completed yet but the service user was a recent admission and their needs were changing on a daily basis. Staff members were using the care plan produced by care management
Warley House DS0000002881.V295656.R01.S.doc Version 5.2 Page 12 and collating information in daily records and other charts in order to produce their own individualised plan of care. In discussions with staff it was evident they were aware of the service users needs. There was evidence of input from health professionals, GP’s, district nurses, community psychiatric nurses and dieticians. Sitting scales had been provided and service users were weighed monthly or more often as required. One case file was examined of someone who had recently died. The home completed information on admission regarding funeral wishes and arrangements. Daily records indicated that monitoring charts were completed in relation food, fluid and pressure relief and care staff sat with the service user. Family members were involved and specialist equipment, such as an airflow mattress was obtained from the district nursing services. Service users described care that respected privacy and dignity, they are lovely girls, they close doors and yes they draw the curtains, they knock on doors and they leave us in peace if we need it. Mail was delivered unopened, people were able to see visitors in private if they chose to, and staff called people by their preferred name and spoke to them in a nice way. Staff also explained how they supported service users to maintain privacy and dignity, We ensure clothes are labelled and that people have their own belongings, we get to know them and know what items are theirs, we knock on doors and explain what we are doing, we make sure they are comfortable and cover with towels when completing personal care, we make sure they can do as much as possible for themselves, to be independent, talk them through things and explain things. Staff had an overall understanding of the needs of people with dementia and were seen to be patient and kind when interacting with them. Visitors spoken to confirm this, the care is 101 . Medication was managed well. It was stored, administered and recorded appropriately. Warley House DS0000002881.V295656.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 at least once during a 12 month period. 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 home provided flexible routines and ensured people were able to make choices about aspects of their lives. A lunch observed was not the relaxed, social occasion for the service users at the first sitting as there was insufficient staff supporting them. The manager showed a good understanding of this and there is a good capacity for the service to improve. EVIDENCE: The home had various separate rooms to accommodate a range of activities, including relaxation with soft lights. They recorded activities provided and who had participated and there was one staff member dedicated for day care services and activities. The activities on offer ranged from one to one and group sessions to visits to local shops and facilities and some occupational tasks such as setting the table, wiping tables, pot planting and sweeping the patio. One service user spoken to stated, I like to sit with my friend, we watch TV and sit and chat in our own lounge, another stated, I like playing bingo on Fridays and another, I like sport on TV, the world cup and now golf. They stated there were no set times for going to bed or getting up.
Warley House DS0000002881.V295656.R01.S.doc Version 5.2 Page 14 A relative spoken to felt they were always welcomed and offered refreshments and service users spoken to stated their visitors could come at anytime and could be seen in private. One person stated, when asked about choices, they ask whether you want an apron on at lunchtime to protect your clothes and you can smoke if you want to. ‘The optician comes here, but I have my own optician and one person told of going out to visit their own dentist. They confirmed there were no set routines other than general mealtimes. Some service users continued to practice their religion and clergy visited regularly. Staff spoken to were conscious that some service users with memory impairment were not able to make a lot of choices but they stressed they tried to assist this as much as possible. Service users spoken to stated that the meals were very, very good. Menus offered choice and alternatives at all meals, including cooked breakfast. The meal sampled on the day was well cooked and presented. The home catered for special health diets, for example, diabetics and individual preferences such as a vegetarian diet for one person and international dishes for another. Two sittings at mealtimes were observed, the first was for five service users who need assistance to eat. This was observed as quite a noisy sitting with one staff member supporting two people to eat at the same time sitting between them and another standing beside the service user to assist with a drink. Another staff member did come to assist but this was rather too late. The manager stated normally 1-1 support was available at lunch time. There was evidence though that the staff member encouraged independence by passing the cup for the service user to hold themselves. There was lots of affection noted between service users and staff throughout the two sittings and the second one was a more relaxed and social occasion. Warley House DS0000002881.V295656.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel safe, listened to and that their complaints will be addressed. The home protects service users from abuse by training staff, good recruitment and adherence to policies and procedures. EVIDENCE: The homes complaints policy was on display in the entrance and staff also have a book to write in. Recorded complaints were minor in nature and were addressed appropriately. One complaint was from a service user who felt rushed at lunchtime and this was addressed with the particular staff member. It was an example of how the service user felt able to complain and that it was dealt with satisfactorarily. Service users spoken to stated they would complain to the manager, whilst one person pointed out their keyworker stating they would complain to them. Relatives spoken to were aware of who to speak to. All staff within the home had received training in the protection of vulnerable adults from abuse and all had signed to say they had read and understood the adult protection policy and procedure. Several staff including the manager had completed training by the local authority. The home had policies and procedures in place and staff members spoken to were aware of what to do if they suspected abuse had occurred. In the past the home recruited staff members in a way that protected service users and ensured that appropriate documentation was in place prior to the start of employment. Warley House DS0000002881.V295656.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The slow progress of renewal of the facilities, fixtures and fittings and redecoration means that service users live in an environment that in parts is inadequate. EVIDENCE: A full environmental check was completed. It had to be noted that the home required a huge improvement plan when the new proprietors leased the property from the local authority as the décor and facilities were poor. Improvements have been made but the progress is slow and timescales on the refurbishment and redecoration plan have not always been met. Some improvements were noted since the last inspection, mainly in the area of under sink work in bedrooms and the garden area, which was much improved. Curtains had been replaced in one of the bedrooms and redecoration of bedrooms had started. The foyer carpet had been replaced and the area redecorated. Warley House DS0000002881.V295656.R01.S.doc Version 5.2 Page 17 The internal environment however was in need of further attention and this was discussed with the manager. The maintenance person had been concentrating on the under sink work but now the manager feels redecoration can be completed in the remaining bedrooms therefore improving the quality of life for people and the appearance of the home. The hallway carpet near the dining room and the stair carpet at both ends of the building was in need of cleaning or replacement as it was badly stained. The manager was aware that approximately ten bedrooms were in need of redecoration and one of them needed some plaster repair work. A leak in one of the corridors upstairs had been repaired but needed redecoration and other corridors had chipped and unsightly paintwork. On the day of inspection one bedroom had an outbreak of ants in one corner and the service user was provided with an alternative room whilst this was treated. Some furniture needed replacement, however one chest of drawers belonged to a service user, so a sensitive discussion about repair or replacement was required. Bedroom doors had privacy locks and the majority of bedrooms had lockable facilities. Those bedrooms examined were personalised to varying degrees. Staff spoken to recognised the environmental shortfalls and a relative spoken to stated, ‘it’s not the poshest home but the care is 101 ’. There were sufficient numbers of toliets and bathrooms for the service users and all but one of the bathrooms had been repainted but some required new flooring as did some of the toilets. Two of the toilets needed a repair of toilet roll holders and another a new chain. Some bedroom carpets needed cleaning and one of the rooms had a strong malodour. The manager was aware and was dealing with it. There was evidence that district nurses had been consulted regarding safety aspects for two service user regarding sleeping arrangements at night and any bedrails were fitted and supplied by the local authority. Warley House DS0000002881.V295656.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a well trained and appropriately recruited staff team. EVIDENCE: The home had sufficient staff on duty throughout the day and night and designated staff for day care and provision of activities. The inspector received very postive coments about staff from service users and relatives. Lovely girls, my keyworker is very nice, she does all sorts for me, the staff are very nice. One person said that staff were nice to him and looked after him well. Relatives spoken to stated, from the cleaner to the top person, the staff are very good. They said they were on first names with the staff and were kept informed by their relatives key worker (they knew the key workers name). There was a low staff turnover and those spoken to clearly enjoyed their jobs and knew the service users well. There was genuine warmth and affection noted between staff and service users. They were clear about their role, knew what was expected from them and showed a good understanding of the actions they needed to take to meet and promote equality and diversity. Recruitment could not be tested as there had been no new staff employed since the last inspection but previous inspections had found recruitment to be completed appropriately. Warley House DS0000002881.V295656.R01.S.doc Version 5.2 Page 19 A training plan was in place and a log maintained of training completed although this was not fully up to date and staff advised of training that had taken place but had not been inputted into the log. The manager confirmed certificates of recently completed training were about to be recorded into the system. Training consisted of in-house training, distance learning and external facilitators. National Vocational Qualification training exceeded the target of 50 of care staff trained to level 2 with the remaining care staff enrolled or progressing through the course. This was a good achievement. In discussion staff reeled off a variety of training courses they had attended and felt they were well trained for their roles. Specialist training in dementia care was provided inhouse and the manager had collated health and social care information in a resource folder for staff information. All staff had completed a refresher induction in the new skills for care induction standards. Warley House DS0000002881.V295656.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The regstered manager is proactive in providing a safe environment for service users who live at Warley House and staff who work there. EVIDENCE: The manager had completed her Registered Managers Award and was enrolled on the NVQ Level 4 in care to start in September. She managed the home well and staff members were positive about her level of support to them. Service users spoken to knew the managers name and some mentioned they would tell her if they had any complaints. A relative spoken to was complimentary about the manager and said they would see her if they had any issues to discuss. Service users views about the home were obtained via meetings and quality assurance processes. The latter consists of audits completed by various staff members and questionnaires sent out to service users, relatives, professional
Warley House DS0000002881.V295656.R01.S.doc Version 5.2 Page 21 visitors and staff. Action plans were produced to address shortfalls and staff were informed of the results and the action required to put things right. Results of the survey were distributed around the home. The propristors produced a business service plan on an annual basis and made this available to the home. There was evidence that the home managed the finances of service users appropriately. Mainly families managed finances but a small amount of personal allowance was held at the home for several people. Individual records and receipts were maintained and the manager audited finances on a weekly basis. Some service users managed their own finances, especially their personal allowances. Supervision records indicated that this was happening regularly and was well recorded. Issues discussed covered topics such as training needs, service user issues and policies and procedures. There was also evidence of staff instruction especially for new staff, for example in areas such as bathing, application of creams, what to do to maintain continence and how to use a slide sheet. There was also evidence that the manager had completed random finger nail checks of service users and discussed this with staff. Care plans focussed on risk assessments and how to maintain a service users individuality. The manager and staff team actively encouraged equality and diversity and this was highlighted by catering needs, religious observances and individual service user preferences. Fire training had been completed and health and safety was observed by staff. The manager had taken advice from professionals regarding the risks to particular service users Warley House DS0000002881.V295656.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 X X 3 X 3 X 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 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X 2 X X 2 X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 Warley House DS0000002881.V295656.R01.S.doc Version 5.2 Page 23 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 OP15 Regulation 12(1)(a) and 18 Requirement The registered person must ensure that sufficient staff members are deployed during the assisted meal sitting to make this a relaxing and social event for service users. The registered person must ensure that the maintenance plan includes timescales for the redecoration of the remaining bedrooms, toilets and bathrooms, the redecoration of the damaged upstairs corridor and paintwork in the downstairs corridors and the refurbishment of some bathrooms and toilets especially flooring. The ant infestation and missing/broken light bulbs were addressed on the day of inspection. The registered person must ensure that minor fixtures in toilets are repaired. The registered person must ensure that broken furniture in bedrooms is repaired or replaced. The manager to audit bedroom furniture for attention.
DS0000002881.V295656.R01.S.doc Timescale for action 18/08/06 2. OP19 23 31/08/06 3. 4. OP21 OP24 23 23 31/08/06 31/08/06 Warley House Version 5.2 Page 24 5. OP26 23 The registered person must 31/08/06 ensure that the badly stained carpets near the dining room and on the stairs are cleaned or replaced and carpets in some of the bedrooms cleaned. The unpleasant odour in one of the bedrooms must be eliminated. 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 OP31 OP15 Good Practice Recommendations The registered manager should complete NVQ Level 4 in care to work alongside their management certificate. The registered manager should ensure that staff members are reminded to sit down next to service users when assisting them with drinks. This did happen when staff supported someone to eat. Warley House DS0000002881.V295656.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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