Inspection on 11/06/07 for Warrens Hall Nursing Home

This inspection was carried out on 11th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Warrens Hall Nursing Home 23/05/09

Warrens Hall Nursing Home 20/08/08

Warrens Hall Nursing Home 05/06/06

Warrens Hall Nursing Home 07/11/05

Warrens Hall Nursing Home 09/05/05

Warrens Hall Nursing Home 10/01/05

Warrens Hall Nursing Home 14/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Warrens Hall Nursing Home 218 Oakham Road Tividale West Midlands B69 1PY Lead Inspector Mrs Cathy Moore Unannounced Inspection 08.10 11 and 14th June 2007 th 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 Warrens Hall Nursing Home DS0000004853.V330726.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. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Warrens Hall Nursing Home Address 218 Oakham Road Tividale West Midlands B69 1PY 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) 01384 455202 01384 240068 starrs.p@bupa.com ANS Homes Limited Brenda Essom Care Home 56 Category(ies) of Old age, not falling within any other category registration, with number (56) of places Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user identified in the variation report dated 29.7.04 may be accommodated in the category PD(E). This will remain until such time that the service users placement is terminated. 2/1/07 ( Random ) 5/6/06 ( key) Date of last inspection Brief Description of the Service: Warrens Hall Nursing home is partly purpose built. The original part of the home that served as the original home is a converted farmhouse. This has been added to and converted to provide a 56 bedded home registered to provide nursing care to older people. The home is owned and managed by BUPA who have a number of other home’s in the area. Warrens Hall is close to a golf course and adjacent to riding stables. There are pleasant views from the back of the home of open fields. It offers generous garden space with a courtyard patio area to the rear. The home has car parking space at the front of the home. Resident accommodation is spread over three floors ( This includes Rowley Unit which at the present time is not being used by the home) and has three distinct units known as Rowley, Malvern and Clent. The home offers in total 40 single en-suite bedrooms, 4 single without en-suite facilities and 6 double rooms. The home provides three lounges and two dining rooms. The home has two passenger lifts enabling resident access to all floors. Weekly fee rates for Warrens Hall range from £439 to £630. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over two days by one inspector. On the first day the inspection took place between 08.10 and 20.45, on the second day between 11.30 and 15.30. Prior to the inspection questionnaires were sent to the service, service users’ and relatives to gain information and their views about the service provided. During the inspection I spoke with eleven staff, five visitors and six service users’. The manager was involved with the inspection over the two days. I looked partly at the premises to include four bedrooms, both lounges and dining areas, the kitchen, bathrooms, toilets, garden. This to assess the general up keep of the building, the suitability of the building in terms of meeting service user needs, health and safety and infection control. I observed the breakfast time on the ground floor to assess choice options and the quality of the food. I looked at service user files to assess care plans and records. I looked at staff files to assess recruitment and training processes. What the service does well: The home is owned and managed by BUPA. This is a large organisation with homes’ nationwide. Support and guidance is therefore available from other homes and managers in the area. The home is a large detached building. It is located in a pleasant residential area, which offers panoramic views to the rear. The home has a new manager who has the required qualifications. The Commission has approved her as a fit person to be in charge of and run the home. The home has an open visiting policy and encourages service users’ to maintain contact with family and friends. Relatives provided the following examples of areas in which they feel the home does well; Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 6 The home is always kept clean. The residents all look cared for and the staff appear to be cheerful. The Care home looks after the residents needs and welfare really well. Nothing is too much trouble for them always willing to help you with any questions. Care home looks after people in general. Provides well trained carers and nursing staff. Pleasant environment and well cared for property. Open visiting times, feel you can contact the home to raise any concerns. My .. is very happy. The staff look after her well and are pleasant and caring. My.. enjoys the meals and always says the staff are very good. Keep them fed and clean well daily. The home provides good nursing and residential care along with creating a warm friendly atmosphere in the home itself. The first thing I noticed when I first entered the home was how friendly everyone was. They talk to my mother with respect which I think is very important. The home is very clean and the food is excellent. Keeps all rooms warm. The menu is varied. A pleasant atmosphere is created . A monthly newsletter of forthcoming events, celebrations and national events. What has improved since the last inspection? A new assessment of need and care planning process has been introduced which will ensure that care is arranged and delivered to suit individual service Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 7 user needs and preferences. This system also has robust risk assessment systems included to ensure that risk is identified, managed or eliminated. The new manager has increased control, working practices and accountability within the home. Whilst a number of staff ( Four of eleven sampled ) are upset by these new working practices the majority welcome the changes and confirmed that they have improved the care and services provided by the home as follows; “ Think things have improved lately. The manager has tightened things up and is making sure people are working as procedures.” “ The changes are better, Brenda ( The manager) goes around everyday to see how the service users’ are which never happened before”. “ I can see the changes really paying off “. The manager and organisation have a clear redecoration and maintenance programme in place. A number of areas such as corridors and the main reception have been redecorated since the last inspection. Hand free phones have been provided to ensure that the phone is answered in a timely fashion outside of business hours. Regular staff and relative meetings have been introduced to inform everyone of changes that are going to happen and to give people the opportunity to ask questions and air their views. Better house keeping processes are in place which has increased the cleanliness within the home. Meals and nutrition have been focussed on. Staff have noted overall, that service users’ weight is being better maintained. A new deputy manager has been employed to give support to the manager and monitor the overall service provided by the home. What they could do better: The home must be able to demonstrate at all times that it can meet specialist and complex needs. Where there is doubt then reassessment must be requested from funding authorities and appropriate action taken. Suitable continence aids must be available at all times to ensure that service users are not at risk and are comfortable. Activity provision within the home must be improved to ensure that there is adequate stimulation and occupation to meet individual needs. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 8 The home must be proactive in encouraging relatives to air their concerns and worries. Regular meetings must be held with individual families to discuss care and inform them of progress or other and to give feedback where concerns have been raised. Staff must be trained to ensure that they know the correct processes if a relative makes a complaint to ensure that the manager becomes aware of all complaints and that appropriate action is taken. Staffing levels must be increased and maintained to a satisfactory level thereafter; to ensure that service user needs are met and that they are safe. Contingency planning must be introduced to ensure that there is adequate staffing cover if any one phones in sick, this to include weekends. The present ‘unrest’ amongst the small number of staff must be managed and resolved to provide a more positive atmosphere and better working relationships within the home. Training opportunities and one to one supervision of staff must be increased to ensure staff know what is expected of them. Hot water pipe work in the home must be suitably guarded to prevent risk of burns. Wardrobes in the home must be secured to prevent risk of accidents. Relatives provided the following examples of areas in which they feel the home needs to improve; The resignation of one of the activities staff has resulted in less activities and entertainment being carried out. Our mother enjoys the stimulation or something different even if she is not capable of joining in, otherwise everyday is the same as the next. Our .. was previously in a residential home where they carried out 6 monthly reviews- meetings between relatives and appointed carer to discuss the residents health etc we think there is opportunity to have a short meeting on a regular basis would be helpful. At the moment the reception is very .. no flowers or plants it has recently been redecorated but lacks any warmth or decoration to make it a pleasant place to enter. Improvements being made all the while for the better. Apply a continuous improved environment . Some of the fittings and furnishings are rather tired though I believe work is already in progress to rectify this. So far satisfied. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 9 No I don’t think I can think of anything that will improve the home. I know my mother is getting all the love she needs. 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. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 10 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 Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 11 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): 2,3,4. Quality in this outcome area is Adequate. New contract documents have been introduced which clearly detail the full cost of the placement for each service user Proposed service users’ can be assured that they will not be offered a placement unless they have been adequately assessed and that the home can confirm that their needs will be met. Attention must be paid to ensure that the on-going specialist and complex needs of existing service users’ are being met to make sure that they are well cared for and safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: I looked in the reception area and saw that there were a range of written documents, which give information about the home such as; the homes Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 12 brochure and last inspection report. Which is good as this information would help new service users’ and their families decide whether or not the home would be suitable. I was surprised to learn from completed service user questionnaires that 7 of 12 ( which was more than half ) felt that they had not been given enough information by the home before they moved in to help them decide if the home was the right place for them. Twelve relative answered the same question their responses were as follows; 5 always, 3 usually and 4 sometimes. This evidence shows that more attention may be needed to ensure that all proposed service users’ are fully informed about the home to help them make what can be a difficult decision about a choice of home to meet their needs. Twelve of thirteen service users’ did not answer the question in their questionnaire about contracts, the only one that did confirmed that they have not received a contract. I did however see, a newly introduced contract on one service user file, which is a big improvement to the previous ones used. This contract has a full breakdown of the fees, which deducts any nursing care contribution. The manager told me that these new contracts either have been or are being introduced for all service users’, which is good, as they will more fully inform them of their rights, and the true cost to them of their placement. I looked at four service user files and saw that new assessment of need processes have been introduced since the last inspection. These are comprehensive, look at each person as an individual, his or her needs, risks, goals and wishes. I had a discussion with the manager about two service users’ who have specialist and complex needs. Evidence that I gained questioned whether the home was meeting these on-going, deteriorating people’s needs. For example; one had severe bruising to her face. The manager could not tell me how this occurred, just that; “ She does sometimes knock her self when she is in her room”. An accident report to account for this bruising was not available. I observed this service user and a number of times I saw that she was for whatever reason distressed, crying and shouting. I also saw her kneeling down on the floor in her bedroom, no staff were with her to give reassurance. The other service user had, had episodes of challenging behaviour, which has now settled to some extent. However, due to the nature of the illness, which is degenerative, it is likely these episodes of challenging behaviour will reoccur. When the behaviour was at it’s most concerning on 7.3.07 the home had told a specialist worker ; “ Worried no longer meeting needs”. I spoke to a person involved who told me that; “Things are better now but that’s because.. is better now”. But also said; “Few months ago when very poorly, the care was not there”. This situation needs further exploration to ensure on-going needs can be met and that these service users’ are safe. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 13 Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 14 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is adequate. The service as far as possible involves individuals in the planning of care that affects their lifestyle and quality of life. Care plans are person centred and where possible are agreed with the individual or their chosen representative. The health care needs of service users’ are managed by visits from local healthcare services. Personal care provision does need some more attention and improvement to ensure that needs are fully met and to protect service users’. Although some ‘fine tuning’ is needed concerning medication. The home has an efficient medication policy supported by procedures and practice. Staff are aware of the importance of proper medication management to ensure medication safety. Staff endeavours to ensure that privacy and is maintained and that service users’ are treated with respect. This judgement has been made using available evidence including a visit to this service. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 15 EVIDENCE: A new care planning system has been implemented in the home. Care plans are structured to look at each service user as an individual, with their care and goals also treated as such. Staff told me; “The care plan system is better than the other one” and “ Care is planned around the service users’ and their routines, rather than the home’s. The care planning system encourages staff to ensure that service users’ or their chosen representatives’ are aware of and involved in care planning processes. I saw that this comment had been made by a relative about one users’ file; 3.5.07 “ Happy with new system, impressed by the detail of plans”. I saw a care plan was available on each service user file I viewed and that these care plans are being reviewed regularly or when changes occur. That care planning has improved is good as this ensures that staff have enough information and instruction to help them care for people living at the home and to keep them safe. The home is registered to provide nursing care therefore a Registered Nurse is available within the home at all times ( two during waking hours, one at night) to carryout any nursing treatments and observations required. I saw evidence on each service user’ file to confirm that they are receiving health care services from the local community when and as needed and that health care is monitored in- house as follows; For one service user records I saw stated that he had been seen by the doctor due to falls on 3.4.07. That his medication had been reviewed by the doctor on 1.5.07, that the home had made a referral for chiropody on 24.5.07 and that he had been reassessed by the Speech and Language Therapist on 4.6.07. I saw records to show that he had been weighed on 29.3.07, 29.4.07 and 21.5.07. For another Service user, records I saw stated that the doctor on 8.9.06 because of a chest infection had seen her. She had been seen by the Speech Therapist on 16.10.06. Audiologist on 16.2.07 . Optician 15.3.07. Dentist on 20.3.07 and Podiatrist on 4.1.07. I spoke with this service users’ visitor who told me; “ Oh yes doctor called when needed and regular chiropody”. Another relative told me; “ Yes they call the doctor quickly enough and enough chiropody”. A staff member told me; “ Yes they have all the services, chiropody and all that. If they are ill the doctor is called right away”. One person I spoke to was not always happy with the healthcare. I was told; “ Few months ago Dr would not give.. any more pain killers or night sedation. It was like a nightmare”. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 16 Overall evidence however, shows that healthcare services are accessed for service users’ to prevent risk and keep them safe. Improvements are needed in respect of personal and continence care. The Commission received a complaint about the lack of continence pads for one service user, which caused the person’ clothing and the pillow they were sitting on to be wet. During the inspection I looked into this issue. I asked the manager on the Monday to show me this person’s bedroom and their stock of continence pads. All that was available were two purple pads to last until the Wednesday. This was obviously inadequate. Two people I spoke to during the inspection told me; “ Pad shortage, last month we ran out”. “ Half the time, there are no pads”. This situation needs some attention and resolution. Pads must be available at all times to make sure that service users’ are kept dry, comfortable and free from risk. I observed a number of service users’ during the day and saw that their hair was nicely done and that they were appropriately dressed. One relative told me; “ Always clean, hairdresser comes in every week”. Another person however, complained; “ Beard has not been shaved, it looks like food is in it. Nails dirty and smell”. I looked at this persons care plan and found that staff, have identified and it is recorded that this person at times is reluctant to have a shave. The care plan said; ‘ Does not want to be shaved for ‘a number of weeks’ on occasions. What I did not see however, were instructions to say how long this situation should be left for and then what should be done, or records to confirm that staff, regularly ask this person to have a shave, but are refused. With the permission of this person I discussed this issue with the manager. Firstly, as previously stated about the home being able to meet this persons on-going needs and secondly that the family may feel happier they are informed when problems arise and if records were available to show that staff have done everything to encourage this person to have a shave, but have been refused. Service users’ were asked the following question in our questionnaire; ‘ do you always receive the care and support you need?’ in response five answered always, five usually, one sometimes, one never and one did not answer. A Registered Nurse is on duty at all times. The nurses and the manager have accountability and responsibility for medication safety in the home. I looked at medication systems in the home. A medication room is available on each floor. The one on the first floor is of a generous size, is clean and airy. It is positive that both rooms are monitored to ensure that temperatures go no higher than 25oc, which is the upper approved temperature for the storage of most medications. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 17 The home has an approved controlled drug cupboard and register to record any controlled drugs held. I checked controlled drugs against balances and found that they were correct. The home uses a monitored dosage system to administer the majority of medications, which generally reduces the chance of errors. I looked at medication records and was pleased that there were no staff initial gaps, to confirm that medication has been given, as it should. I saw that a photo was available to confirm each service users’ identity to prevent error. I saw that there was a medication fridge available to store medications that need to be stored in a fridge and that temperatures are taken to make sure that the correct temperature is maintained. Two issues I did identify were that medication packets are not always date labelled when opened which could prevent effective audits taking place. And that the deputy on the first day of the inspection had identified that tablets were short for two service users’. Whilst it is positive that effective processes are in place to identify shortfalls, to prevent service users’ having to go without their medication. It is concerning that this shortfall had not been identified by the person receiving and counting the medication when it arrived at the home. It is clear that staff try to uphold service users’ privacy, dignity and independence. During the inspection I observed staff talking to service users’ they were polite and friendly. I saw that staff, were careful to shut bathroom toilets and doors when being used for service users’. The preferred form of address for each service user has been determined and recorded on their care plan. A relative commented; “ They talk to my mother with respect which I think is very important”. Care plans contained instruction about what service users’ could do for themselves and instructed staff to give them choices wherever possible. One staff member told me; “ I let them do what they can for themselves. I will not take independence away”. Another staff member told me; “ Yes, we let them do what they can for self. Treat with dignity. It’s their home”. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 18 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. The home tries to ensure that daily routines are flexible to suit individual needs and requirements. Activity provision is being developed and improved to provide adequate stimulation and recreation. The home has open visiting times; service users’ are very much encouraged to maintain contact with family and friends. Processes are in place to promote service user choice and enable them to keep control of their lives where possible. Food provision is varied, nutritious and of a good quality. This judgement has been made using available evidence including a visit to this service. EVIDENCE: I saw on care plans that the preferred rising and retiring times have been determined and recorded in respect of each service user. When I arrived at the Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 19 home at 08.10 I saw that there were only two service users’ up and dressed in the ground floor lounge. This indicates that service users’ are not all made to get up at a certain time in the morning. During the morning I saw service users’ arriving in the dining room at different times. One service user told me; “ Get up when I want”. Staff told me; “ Some do like to get up early. Nobody has to get up, they are all asked and the other way round some like to go to bed early”. Satisfaction about activity provision varies. Thirteen service users’ were surveyed by the Commission. The following question was asked ;’ Are there activities arranged by the home that you can take part in?’ Five answered as always, three usually, one sometimes and three did not answer. Comments were also received about activities which included the following; ‘Bingo, holly communion and other things. I prefer to read and watch TV. The rest of the time I like to be on my own’. ‘Varied and pleasant activity. Enjoyed the picture of butterflies that N made’. ‘ Would welcome a one to one talk’. Staff told me; “ Not really enough activities. Music yesterday. Activity person in today. When weather is nice they sit in the garden. They love that”. I asked a highly dependant service user if they had enough to occupy them and was told; “ No, get bored”. A relative told me; “ Not enough actually. Before people came in and played music they don’t now. The vicar came in last week though”. Evidence gained during the inspection process indicates that the home is aware that there is some shortfall concerning activities and is working to address this. The manager told me about plans for the courtyard garden. Which is being made into a more ‘user friendly’ area. It is hoped that facilities will be available for service users’ who want to be involved in this gardening project. A staff member told me; “ A new activities person has started, so things are getting underway. She is looking at one to one activities at the moment. I think things will progress. The sensory garden will be good that they are planning, so they can do things outside”. The home has open, flexible, visiting times. During the inspection I saw a number of visitors come and go at different times. All service users’ I spoke to told me that they have regular visitors. One service user I observed seemed to have different visitors coming in and out all day. All relatives I spoke to confirmed that they could visit the home at any time. Comments included; “ Make me feel very welcome when I visit. Can come at any time of the day and night”. “ No problem, can visit at anytime. Someone from the family is usually here”. I saw evidence to confirm that service users’ are enabled to vote if they wish. I saw personal possessions in each person’s bedroom making them feel personalised and homely. One relative said;“ Her son brought in a recliner chair for her”. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 20 Our questionnaires asked service users’; Do you like the meals at the home? Responses were as follows; seven said always, five said usually and one sometimes. Additional comments received about food included; “ Fantastic”. “ very good”. “Not been enjoying as I felt poorly”. “ Needs soft food which is fed to her”. Feedback during the inspection from staff and service users’ indicates that food provision has improved . One staff member said; “ Oh the meals have improved, please underline improved. Soft diets in particular, they are made to look so much nicer”. Another staff member said; “ Catering staff went on training course. Improvements- moulds have been brought for soft diets, so even though food is soft it can be reshaped for instance; pureed’ peas look like peas. This encourages people to eat”. The manager told me since the last inspection the cook has been on a nutrition course, which was arranged by the local council. Since this time more fruit and vegetables are being added to food and more attention paid to menus. I looked at food stocks in the kitchen these were plentiful and varied with eggs, meat, fish, fresh vegetables and fruit. The cook had made some homemade cakes, which looked and smelt very nice. The dining room on the ground floor is pleasant. I saw that tables and chairs are of a good quality the floor has laminate style flooring. The room is bright and the tables were nicely laid. I observed breakfast time on the ground floor. One carer had been given responsibility to give out the breakfasts. I heard her asking each service user what they would like, and if they wanted hot or cold milk with their cereals. Hot options of sausage and tomatoes were available for anyone who wanted these. The breakfast was well presented and smelt very nice. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 21 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is adequate. Improvements are needed to make sure that all service users’ and relative are fully aware of complaints procedures and that staff know what they should do if a complaint occurs. Further developments are needed in respect of raising staff awareness in respect of protection issues and feedback to relevant parties on actions taken if a concern or incident of abuse occurs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure, which is available in the home. Analysis of twelve completed service user showed the following; six confirmed they always know who to speak to if they are unhappy, One usually knows, one sometimes knows and four never know. Service users’ commented about individuals they would go if they were unhappy to such as Brenda the manager and N or carers. Two of eleven service users’ confirmed that they know how to make a complaint, one usually, two sometimes and five never. Two of the ‘never’ did state that this is because they have never had to make a complaint. Nine of eleven relatives who were surveyed confirmed that they know how to make a complaint, two, answered no to this question. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 22 During the inspection a visitor did approach the manager with an issue she wanted clarifying. This visitor told me; “ Yes, anything she tells me or her sister then we come to the office”. Another person told me; “ Yes I am aware of the complaints procedure, but it is a waste of time”. I discussed these findings with the manager. Saying that it may be better if the subject of complaints was included as a standing agenda item in service user and relative meetings to better inform them all of processes. And that procedures were produced in different formats appropriate to the needs of the service users’ to raise understanding. As stated in the Health and personal Care section of this report the Commission received a complaint, which I looked into during this inspection. From speaking to a staff it was clear the staff were aware of the concern that this relative had raised but the manager was not. Further, I did not see anything recorded in the complaint book for the day highlighted 13 May 2007, the day this relative highlighted their complaint. This situation shows that staff did not follow procedures as the management were not aware of the complaint and it had not been recorded. This situation is further concerning as similar shortfalls were highlighted in the previous key inspection report dated 5 June 2006 as follows; ‘..This complaint was not detailed in the complaints log as it should have been’. This evidence shows that shortfalls concerning complaints systems remain. Four complaints have been received since the last inspection from anonymous sources. These were received by the Commission and forwarded to the provider. The manager told me these are in all probability from staff members. Higher management have had a staff meeting but no one would come forward. Staff, have been told that it is easier for all concerned if they have concerns that they come forward in person so that issues can be properly discussed and resolved. It is positive that a number of staff, have received abuse awareness training since the last inspection which gives them knowledge of the definitions of abuse and what they should do about it. The manager told me that staff, have not read the Local Authorities Protection procedures as required following the last inspection. She assured me that these would be discussed during the next staff meeting. I was concerned when talking to one someone to discover that her Dad had been the victim of an incident of abuse. Although the situation was reported as it should have been resulting in the staff member concerned being dismissed. The family had not been informed of the outcome of any investigation. This should have happened as a matter of course to give reassurance. This person told me that her Dad also had money and a credit card taken which she had reported to the police. I raised these issues with the manager who responded by sending a letter to the next of kin about the outcome of the abuse situation and assuring me that Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 23 the allegation of the money and credit would have an initial investigation and then be reported to the relevant agencies if needed. Following the last inspection the Commission sent a letter to the manager asking for evidence be provided to confirm that a dismissed staff member had been referred to the Protection Of Vulnerable Adults (POVA) list and Nursing and Midwifery Council ( NMC ). To date this confirmation has not been received. Further when I asked for confirmation again during the inspection I was told that the head office deals with that side of things. I informed the manager that the Commission must be provided with this information and she as registered manager should have written confirmation to satisfy herself to that this legal requirement has been addressed. One other allegation due to bruising has been subject to Local Authority Protection proceedings since the last inspection. However, the service users’ doctor provided information about the probable cause of the bruising and no further action was taken. This service user no longer lives at the home. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 24 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): Quality in this outcome area is adequate. Service users’ live in a reasonably safe, comfortable environment, which does require some redecoration. Safe access to indoor and outdoor communal facilities is provided. Further development and improvement is needed in respect of laundry procedures and general infection control. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Work has been undertaken since the last inspection. For instance the main reception has been redecorated, as have toilets and bathrooms. Plans are being made to improve the courtyard garden area. Redecorating does need doing in a number of areas examples being; one bedroom identified during the inspection, which was highlighted to the Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 25 manager. Paintwork in corridor and landing areas, such as doorframes and skirting boards needs attention. The manager told me that she has a decorating programme in operation that will be worked through. Generally though I saw that the home was nice and bright. A separate lounge and dining room are available on each floor, which are comfortable and safe. Pictures, ornaments and the cuckoo clock on the wall in Malvern lounge for example; make these living spaces feel homely. Two people told me that the bath hoist in the ground floor bathroom has been out of action for some time. One person said; “ It’s been broken for eight weeks. We only have one working bath for 18 people”. The manager told me that a part has been ordered for the bath hoist to rectify this problem. Bedrooms I looked at were mostly comfortable. However, I did detect an odour in two, which needs to be addressed. I was disappointed to once again see laundry in bags directly on the laundry floor. This concern has been raised in previous inspection reports as it could cause a spread of infection in the home. Another issue raised in previous reports is that there is only one sink in the laundry not enabling a dedicated area for staff hand washing. I was concerned during this inspection to see that this sink had clothes soaking in it. The manager told me that; “ Washing should not be soaked in the sink”. Evidence therefore shows staff are not always following instructions and are potentially causing an infection control hazard. I did see that the laundry looked tidier and more organised than it has done during previous inspections. Two relatives I spoke to told me that they would like to see bacterial hand wash available for use on entry and exit to the home. “ Like in hospital so stop us bringing germs in and taking them out”. I told them I would pass this suggestion onto the management. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 26 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is adequate. Staffing levels are not always adequate to meet the needs of service users accommodated. There is some unrest within a small group of staff, which needs to be addressed and resolved. Staff achievement concerning NVQ does not quite meet the required ratio. Further development is needed to ensure that all staff receive suitable induction to equip them with the basic knowledge base needed to undertake their job. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this inspection there were thirty-three service users’ living in the home. A number of these have high dependency needs examples being; people nursed in bed and people who require high levels of supervision and reassurance. I spent time in the lounge areas and was concerned, as there were considerable lengths of time when there were not any staff present. This observation I highlighted to the manager. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 27 Staffing levels according to the set rota show that eight care staff should be provided in the mornings and six in the afternoon and evenings. However, management feel that seven care staff in the morning and five in the afternoon and evening is sufficient and these are in ‘Excess of the Industry Standard ‘. The Commission received a complaint about staffing levels one particular day Sunday 13 May 2007. The complainant stated; “It is always the same , particularly on a Sunday when they are always short of carers”. On this day in question I saw from the rota that the home was short, as a staff member had phoned in sick. I take into account that at times staffing may have been jeopardised by last minute sickness, but from evidence gained from rotas and speaking to people it is clear that this situation occurs fairly regularly. I spoke to a total of eleven staff all but one commented that staffing levels are not adequate as follows; “ My main concern is staffing levels. Lot of the time only two up, two down and one floating”. “ Sometimes we are short at weekends”. “ Not enough staff and some staff we have to carry”. “ Always short of staff. Only two upstairs for nineteen residents”. “Sometimes a bit short”. “ Not enough staff only two up and two down”. “ Not enough staff. Seven in the mornings sometimes not enough neither is five in the evenings. “ Staffing not enough. Four on each floor is a luxury, we then have time to get things done”. Relatives I spoke to told me; “ Probably not enough”. “ I always see plenty”. Service users’ I spoke to said; “ Never seem to be enough staff”. “ Sometimes we have to wait”. “ Yes enough staff”. I spoke with the management about my concerns and reminded them that it not just the numbers of service users’ accommodated, but their needs that have to be taken into account. At the time of the inspection taking into account evidence gained, it was clear that staffing levels are not adequate. Seven care staff in the mornings may be adequate, but will need effective monitoring and increase if necessary. However, five care staff in the afternoons and evenings is not adequate, which was confirmed by staff. Further, better contingency planning for sickness particularly at weekends is needed to ensure that service users’ are safe and well cared for. Management are aware that there is a staffing problem and more staff are being appointed. The home is waiting for the required checks and clearances for these staff before they can commence work. I was told by the majority of people I spoke to over the two inspection days that there is some unrest within the staff team. I spoke to eleven staff in total. Seven of them told me that they were happy with their work as follows; “ Job is ok”. “ Happy, like working here”. “ Happy with job, really happy”. “ Things have changed. It’s a lot easier now, more Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 28 organised”. “ I’ happy here now it’s better”. “ More satisfaction with my job”. “ I love my job I really do”. The remaining four told me for different reasons that they were not happy and a number of other ‘unhappy staff’ have left the home. It is clear that the unhappiness of this group of staff, is having a negative impact on the homes’ atmosphere. One staff member told me; “ I feel in the middle”. Further, it is apparent that a few relatives are being told about the unhappiness felt by this small group of staff. I was concerned to be told by the manager that at times staff refuse to carry out her instructions. For example; when I mentioned to the manager my concerns about the lack of staff presence in the lounge she asked a staff member to go in there. This staff member refused. The management have confirmed that they have tried to address this staff unrest by holding regular staff meetings and a meeting with relatives. However, this situation in order to promote good relationships in the home and a positive atmosphere needs to be resolved. The home has nearly met the requirement of 50 of the staff group to have an NVQ award. Other staff are working toward this qualification at the present time. To continue to meet the required 50 ratio and ensure enough staff have been assessed as being competent to undertake their care duties, new staff being employed must be enrolled onto this training at the first opportunity. I looked at staff files and was pleased to see that recruitment processes are adequate which is good as this helps to protect service users.’ In general evidence was available to confirm effective induction training to promote service user safety and well- being. However, I did note that there was no evidence to confirm that one new staff member has had induction training. The manager confirmed at times this person covers ‘ care’ shifts. Shortfalls in staff induction training were also highlighted in the last inspection report dated 5 June 2006. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 29 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): 31,33,35,38. Quality in this outcome area is good. Since the last inspection a new manager has been appointed. The Commission as a fit person to run and be in charge of the home has registered her. Processes are in place to enhance service user and relative involvement in the running of the home and for them to give their views about the home. Service user money is held securely to ensure that it is safe. Some ‘fine tuning’ is needed, but generally health and safety observance within the home is satisfactory. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 30 A new manager has been appointed since the last inspection. She is a Registered Nurse and has considerable experience in providing care to older people in services registered by the Commission. She has been approved by the Commission as a fit person to be in charge of this home. From speaking to the manager I discovered that she is clear about her role and is committed to making changes to improve the safety of service users’ and their quality of life. The staff team have differing views about the new management a small number employed as stated in the previous section of this report are unhappy. They feel that they are treated unfairly and not valued. However, the majority ( seven of eleven staff sampled) feel that the new manager has improved the home.“ Standards have improved to some degree. In the past care assistants left to get away with a lot. They have been pulled back and do not like it. In some ways, maybe too much, the other way. I think the manager is approachable”. “ The standards are getting better now. I’m happy with the manager. I feel ok to approach her”. “Comfortable with Brenda”. “ The changes are better. I like Brenda, she says what she thinks. Approaches you if there is anything, which is good”. “ Brenda is the most recent manager. Really trying to get the standards up. Sometimes she has to put her foot down and say ‘ this is what should be done’. Staff oppose. Brenda is right. Some are very set in their ways”. “ I am treated well and respected as a staff member. It is totally different from before. Things are being done and I can see why. Before laid back attitude. All management approachable. No one in an ivory tower. Brenda knows everyone by name”. The home is owned and managed by a large organisation BUPA. BUPA have processes in place for quality monitoring across all areas of practice. The manager is responsible for some quality monitoring for others staff external to the home carry out the monitoring function. I saw evidence to confirm that satisfaction surveys are used in order to gain the views of service users’ and relatives. Similarly, it is positive that meetings are held for service users’ and relatives for information sharing and for them to air their views. Service user money is held in a bank account which increases money safety. A written record is maintained for each individual detailing any deposit or expenditure. A ‘float’ of £32 is kept in the home to enable access to money. The administrator and manager confirmed that service users’ do not often ask for cash only holding this small amount is not a problem. As with the last inspection carried out in June 2006 I identified from training charts that gaps do remain in respect of mandatory training. The manager confirmed this. The senior manager told me that action is being taken to improve in this area. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 31 As with the last inspection I saw that two wardrobes were not adequately secured which could cause an accident if pulled over. These were pointed out to the manager during the inspection. I also noted that there was no evidence to confirm that two electrical items belonging to service users’ had been deemed safe. When looking at the premises with the manager we saw that some metal hot pipe work, examples being; at the top of baths, was not suitably guarded and could present as a burning risk to service users’. I randomly looked at service certificates to ensure that equipment and appliances are being checked to make sure that they are safe and in good working order. The passenger lift was serviced on 8.5.07. The hoists serviced on 30.5.07 and the fire alarm system was serviced on 21.5.07. I was told by the manager that the homes’ electrical wiring had been tested recently and was satisfactory however, the certificate to confirm this had not yet been received. A gas safety certificate had been issued on 2.4.07 there were a few issues highlighted that may need further attention and action. I looked at the kitchen and found that it was reasonably clean with good records to evidence actions taken to promote food hygiene. However, the problem of effectively being able to clean under some units remains. Appliances looked cleaner than I had seen them in June 2006. However, I saw dried on fat down the inner side of the deep fat fryer. Although dried foods are stored in air tight containers to prevent contamination the staff are not entering the use by dates from original packaging on the new containers preventing then from knowing when the recommended use by dates have expired. A requirement was made following the last inspection about risk assessments of equipment. When I was in the kitchen with the manager I asked a member of the catering staff about risk assessments for the deep fat fryer she was unable to answer. This showing that staff in the kitchen may be not fully aware of risks to them or methods in place to reduce risk. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 32 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 2 2 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 3 x x x x x 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 33 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 OP4 Regulation 13(4)( c) Requirement The service users with a diagnosis of Huntington’s must be fully reassessed to determine whether or not the home can fully meet their needs. This requirement has been made to make sure that the home can meet these service users’ needs and keep them safe. Adequate and suitable continence aids must be available at all times for service users’ who need these. This requirement has been made to make sure that service users’ are properly cared for and are safe. Timescale for action 21/07/07 2 OP8 13(4)( c) 15/07/07 Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 34 3 OP9 13(2) The date of opening of all medication containers must be recorded to allow medication audits to be completed. Medication coming into the home must be counted to ensure that amounts received are correct and accurate against amounts prescribed on the prescription. These requirements have been made to increase medication safety and prevent risk to service users’. 15/07/07 4 OP16 13(4)( c) 22(3)(4) All complaints and concerns must be recorded in the complaints log. They must be investigated within 28 days- the outcome of which to be provided to the complainant. Timescale of 01/07/06 not fully met. 15/07/07 5 OP18 13(6) 6 OP18 13(6) If an allegation or incident of abuse occurs relatives and significant others’ must be kept updated and informed of the outcome. The manager must have adequate documentation on site to prove that ex staff where needed have been referred to the appropriate bodies examples being; POVA list, NMC. 21/07/07 21/07/07 Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 35 7 OP26 13(3) The registered provider and manager must ensure that; Dirty laundry/ laundry is not stored directly on the floor. Timescale of 20/06/06 not fully met. This requirement has been made to prevent infection risks in the home and keep service users’ safe. 23/07/07 8 OP27 13(4)( c) Adequate staffing levels must be provided during all day time hours as follows; No less that 7 care staff in the mornings and no less than 6 during the evenings. These must be increased accordingly if service user numbers and needs increase. Contingency planning must be put into operation to make sure that there is enough cover if people go off sick especially at weekends. This requirement has been made to ensure that service users’ needs are met and that they are safe. The unrest within the staff group must be managed and resolved. This requirement has been made to reduce risk and keep service users’ safe. 15/07/07 9 OP27 13(4)( c) 18(1)(a). 01/08/07 Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 36 10 OP38 13(4)( c) The registered provider and manager must ensure that all wardrobes are suitably secured to prevent accident or injury. (Timescales of 01/06/05 and 01/12/05 not fully met). 13/07/07 11 OP38 13(4)( c ) 18(1)(a) All staff receive the required mandatory training. This requirement has been made to protect service users from risk and keep them safe. Timescale of 01/10/06 not fully met. 01/09/07 Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 37 12 OP38 13(3) The kitchen mop situation is resolved to allow staff to effectively clean under all kitchen work stations, fridges etc. All equipment must be cleaned thoroughly to prevent a build up of grease. Timescale of 01/07/06 not fully met. 15/07/07 13 OP38 13(4)( c) All exposed hot pipe work throughout the home ( examples being under hand wash basins and at the head of baths) must be suitably guarded. All electrical items brought into the home must be checked to make sure that they are safe before they are used. These requirements have been made to prevent risks and keep service users’ safe. 20/07/07 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 Refer to Standard OP8 Good Practice Recommendations Action must be taken at all times to ensure that all aspects of personal care to include shaving and nail cleaning are carried out. Where care has been offered and refused this must be recorded. Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 38 2 OP12 The registered person and manager must ensure that the activity providers are trained in special need activity provision an example of which being dementia or for non speaking persons. A concise record of each service users’ activity participation must be maintained at all times. 3 4 OP15 OP16 Menus are produced in formats appropriate to the residents’. ( large print/pictorial). The registered provider and manager must ensure that the complaints procedure is appropriate to the needs of all residents’. 5 OP18 All staff must read when reviewed the homes’ and Sandwell Councils’ adult protection/ abuse procedures. They must all receive abuse awareness training. The bath hoist in the ground floor bathroom must be repaired or replaced as soon as possible. A second sink for ‘hand washing’ purposes should be made available in the laundry. The registered person and manager must ensure that all new care staff receive formal induction/foundation training to ‘ Skills for Care standards’ within the first 6 weeks of appointment. All staff must be aware of any risk assessments concerning equipment that they have to use such as; the deep fat fryer in the kitchen. 6 7 8 OP22 OP26 OP30 9 OP38 Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Warrens Hall Nursing Home DS0000004853.V330726.R01.S.doc Version 5.2 Page 40 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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