Inspection on 30/08/06 for Waxham House

This inspection was carried out on 30th August 2006.

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

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

Other inspections for this house

Waxham House 30/10/08

Waxham House 07/12/05

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Waxham House Waxham House 1 High Park Road Ryde Isle of Wight PO33 1BP Lead Inspector Liz Normanton Unannounced Inspection 30th August 2006 09:40 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 Waxham House DS0000064160.V299398.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. Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waxham House Address Waxham House 1 High Park Road Ryde Isle of Wight PO33 1BP 01983 564326 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) Mr Sanjay Prakashsingh Ramdany Mrs Sandhya Kumapi Ramdany Jamie Louise Bunter Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20), Physical disability over 65 years of age (4) of places Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: Waxham House is situated within a residential area of Ryde and is a short journey by car from the facilities and amenities of Ryde esplanade and the town. Walking to these services and conveniences would, however, be beyond many of the clients accommodated at the home, a result of the distance, although public transport (buses) is accessible nearby. The premises is a large period town house, which has been adapted to provide residential accommodation with a lift to the first floor or chairlifts, which can be used to access both the mezzanine and first floors if required, the home having two separate landings accessible by different stairways. Weekly Fees: £443.00 Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and focussed on what the Commission considers to be core standards for a care home for older adults as defined in the Department of Health (DOH) National Minimum Standards. Information was gathered from a variety of sources, which included data being sent to the Commission prior to the site visit, discussion with several service users and written feedback from three service users, one care manager, four relative comment cards, discussion with two staff and the manager, and the viewing of staff and service users’ files. This information was then triangulated to access outcomes for people living at the home. The overall outcome is that residents are very satisfied with care provided by the home. What the service does well: What has improved since the last inspection? There have been improvements to the environment with several bedrooms having been redecorated. A small fishpond has been installed in the rear garden. New home entertainment systems have been installed into the living room, which includes a hi-fi system, a wide screen television, which was donated, and DVD player. A coldwater dispenser has been installed in the dining room. Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 6 The laundry has now been partitioned to provide a separate area for the storage of food provisions. A new fridge, dishwasher, cooker have been purchased to replace old items. The manager has developed further quality assurance systems. All residents and relatives have been consulted about the service since the last inspection. Residents’ meetings have been introduced which are held with the proprietors every three months. The proprietors have implemented a programme of maintenance and renewal. 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. Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home does not admit residents until having completed a needs assessment to ascertain whether the home can meet an individual’s needs. EVIDENCE: The home displays a statement of purpose/service users guide in the reception hall and copies were also seen in vacant bedrooms. A relative spoken with stated that they had received written information about the home to enable them to choose if it was what they were looking for. Four residents’ files were viewed and were found to contain a needs assessment. The manager reviews the assessment on a regular basis and makes changes to the care plans as necessary. In discussion with a relative they confirmed that the home’s manager had been out to their home to undertake a needs assessment prior to admission. Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 9 In discussion with the manager they stated that either they, or the proprietor would be responsible for undertaking needs assessments. Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care, which a resident receives, is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Each resident has an individual care plan using information which has been gathered from the needs assessment. Four residents’ files were viewed and the information in the care plans was found to be comprehensive and enabled staff to understand residents’ needs. In discussion with two staff they stated that they had read care plans and find the information in them enables them to understand an individual’s needs. Written and verbal feedback from residents was positive with them all being well cared for. Residents spoken with knew they had care plans but not all were involved in the review. Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 11 In discussion with the manager they stated that the deputy managers are key workers and are responsible for reviewing and updating care plans, and residents are involved when there are any changes in information. Each file also contained evidence of risk assessments. The home meets residents’ health care needs. Each resident can choose which surgery they wish to register with on admission to the home and are able to remain with their own GP if the practice covers the home. One resident was supported to visit the dentist during the inspection visit. In discussion with one resident they said the doctor had been to see them recently. There was also evidence on file of doctors’ visits to the home. A chiropodist visits the home every six weeks. In discussion with staff they confirmed that nobody at the home has pressure sores and that if there were any concerns they would call the district nurse. One resident consulted with the manager about their health and the manager dealt with this in a professional and confidential manner. A coldwater dispenser has been purchased and is situated in the dining room; this was to enable residents to access cold water as required during the heat wave. It was also noted that fans were situated in the communal areas and in several bedrooms. The home has safe systems for the storage of medication. Several of the Medication Administration Records (MAR) sheets were viewed and there were no omissions. Medication is ordered monthly and delivered weekly. The home uses the Nomad system, which means medication is pre-dispensed into a specialist container by the pharmacist. There was evidence that unused medication is returned and a record of this is kept. Those staff responsible for the administration of medication have received in-house medication training. Details of medications, and why they are being taken, and what possible side effects might be is also held in individual files for staff information. Residents were observed being treated with dignity and respect throughout the inspection visit. In discussion with residents they confirmed that the staff treat them with dignity and respect. In shared rooms privacy was provide by way of partition walls and the use of curtains. One resident confirmed that the staff always ensure that the curtain is pulled across whilst personal care is being given. Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 12 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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to choose their lifestyle, social activity and keep in contact with family and friends. The home’s social, cultural and recreational activities meet residents’ expectations. Residents receive a healthy, varied diet according to their assessed requirement and choice, however there are some issues in this area. EVIDENCE: At the inspection visit a musician visited the home in the morning to play a keyboard and residents were provided with a songbook to enable them to sing along. Several residents were joining in with the sing-along whilst others chose not to participate. A social activities programme is displayed in the home. Activities available include chair exercises, bingo; Connect Four, beetle drive, scrabble, music man and a quiz. A hairdresser and manicurist also visit the home regularly. The home has well stocked bookshelves situated in the sitting room. Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 13 The sitting room is also equipped with a wide screen television, DVD, and hi-fi system. Residents also have home entertainment equipment in their bedrooms, which they have brought with them. There was photographic evidence of a trip to the local bowling alley. Visitors are welcome at the home and feedback from relatives was positive with them feeling welcome. The home has a visitors’ book and entries are made into this. There were several visitors who called at the home during the inspection visit. Whilst speaking with staff they confirmed that residents go out into the community with their relatives. The manager stated that one resident attends the local church fortnightly and is supported by a member of staff. Holy Communion is provided once a month for those residents who wish to attend. In discussion with residents they confirmed that they are able to make choices. Three residents manage their own finances whilst others have chosen to have it in safekeeping. In consultation with staff they stated that residents can choose what to wear, time of waking up and retiring, choice of meals, joining in activities etc. In discussion with the cook they stated that residents are offered a choice of cereals, toast, prunes and fruit juices for breakfast. A member of staff felt that the quality of cereals was poor, with branded named cereals being replaced with economy cereals. No cooked breakfast is available during the week. The sample menus sent prior to the inspection demonstrate that there is a choice of two main meals at lunchtime. At the time of the inspection visit the choice was chicken curry with rice, or pork casserole with vegetables. The cook stated that they consult with residents to ask what meals they would like to be prepared in the home. Diabetic diets are also catered for. Drinks and biscuits are provided between meals and residents can ask for drinks and snacks throughout the day as required. The home receives fresh vegetables and fruit twice weekly and also uses processed and frozen produce. The menus offer a nutritional and varied menu. The teatime meal is made by the care staff and is usually a sandwich or light snack such as beans on toast. In discussion with the manager they explained that they have had to reduce the variety of choices at teatime as the staff were spending too long in the kitchen. Feedback from relatives and residents has been varied, with some being satisfied with the meals and others not. One relative mentioned lack of Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 14 provisions at the home and questioned purchasing abilities. There were also comments that the quality of meals drops at the weekend. The home undertook a service user satisfaction survey in June 2006 comments on catering and food indicated that the service was good and that people were satisfied. It was evident that there are differences of opinion with regards to the quality, choice and appearance of meals offered at the home and these can be effectively dealt with by listening to the comments and views of service users and staff to ensure that standards remain high. Waxham House DS0000064160.V299398.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to a robust, effective complaints procedure, are protected from abuse and have their legal rights protected. EVIDENCE: The home has a complaints policy and the procedure and is provided to residents in the home’s service user guide. The home has a complaints record log and no complaints have been recorded since the last inspection. The manager explained that residents would often raise issues directly with her or staff but did not want these recorded in a formal way. In discussion with several residents collectively and independently they confirmed that they knew how to make a complaint but were happy with the way things are. The home has an adult protection policy and procedure, which is in accordance with the Isle of Wight Adult protection strategy. Two staff spoken with were aware of the home’s whistle-blowing policy and had not had to use it. They also confirmed that they had read the adult abuse policy and procedures. The home also has a copy of the Department of Health (DOH) NO Secrets Guidance. There was “No Tolerance” to adult abuse posters displayed around the home. In discussion with the manager they are planning to make adult abuse awareness training mandatory. Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 16 Several staff have covered adult abuse awareness training as part of their NVQ modules. There have been no allegations of abuse made since the last inspection. Systems are in place for the safe keeping of residents’ money, which is detailed later in the report. Feed back from residents suggests that they feel safe living at the home. Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The communal areas within the home are easily accessible. The floor space in most bedrooms is small and these rooms do not meet the minimum standards but remain the same as at 16th August 2002. The home is well maintained and provides a comfortable environment, which encourages independence. EVIDENCE: A full tour of the premises was undertaken and the home was found to be clean, safe, comfortable and free from offensive odours. Several bedrooms are in need of being re-decorated and re-carpeted, and there are plans for this work to be undertaken as part of the home’s maintenance programme. The carpet in the dining room is showing signs of wear and tear, however the maintenance programme demonstrates that there are plans to re-decorate the dining room and replace the carpet, dining tables and chairs, replace ceiling Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 18 lights and to generally make the dining room more homely. There are also plans to replace the radiator with one that is more energy efficient. It was noted that the home has purchased new towels to replenish old stock. Pillows in several of the bedrooms could do with replacing as the filling has become lumpy. Seating in two of the vacant rooms was dirty with stains from previous occupants, and requires cleaning. This matter was discussed with the manager, who said the cleaner had the task down on their list of things to do and would be done as a matter of course. Paintwork to one bedroom wall was badly scuffed and unsightly, the manager stated that this room should have been re-decorated prior to the resident having been admitted but the work was overlooked. Four side tables were found to be badly damaged on the surface area and require replacing. Four bedrooms have been redecorated since the last inspection and were done to a high standard. One resident’s bedroom is too small to accommodate a specialist bed, which they would like to bring from home. The home has provided equipment to enable the resident to get in and out of bed but they have to rely on staff to help them and to move them at night. This matter was discussed with the manager who stated that the home had done everything they could to promote the resident’s welfare. The bathroom on the Mezzanine level has now been utilized for residents’ use. The lounge has been equipped with a new hi-fi system, and DVD player. A new wide screen television was donated to the home in May 2006. The living room was large and offered pleasant homely surroundings, however the lighting was poor. There are plans to alter the lighting in March 2007 as well as redecorating the living room to make it look brighter. Food is no longer stored in the laundry area, as a partition has been erected to provide a separate food storage area. However the manager explained that as a result of this there is now nowhere to handle laundry as the area only houses the washing machine and dryer. The manager is considering having a cupboard installed in the dining room for the storage of clothing until it can be returned to residents’ rooms. All residents clothing is labelled or marked to ensure that residents are wearing their own clothes. All staff have received infection control training. Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 19 The laundry is situated away from food preparation areas. is available to staff at all times. Protective clothing One member of staff raised concerns that on occasions tea towels have been washed with bedding and underwear and was very unhappy about this. This matter was discussed with the manager who is aware of the situation and is dealing with the matter. Signs have been displayed to remind staff of laundry procedures. Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff working in the home are trained, qualified and skilled and employed in sufficient numbers to fill the aims of the home and meet the changing needs of the residents. Attention needs to be paid to making the recruitment of staff more robust. EVIDENCE: The staff team has the skills mix, experience and qualifications to meet the assessed care needs of the residents. In discussion with two care staff both felt that there was sufficient staff on duty to manage each shift. One resident was concerned about the staffing arrangements at night, there is one waking night staff and one sleeping in, “What would happen if anything were to happen to the person doing the waking night, there would be nobody to alert the person sleeping in if residents needed help?” This is a genuine concern, however there is nothing unusual about this type of staffing arrangement at night, however the home might want to consider having two wakeful night staff in future when resident numbers increase or care needs become higher. The staffing roster demonstrated that there are three staff on duty in the morning and two in an afternoon. In discussion with the manager they stated that the staff are responsible for the preparation of tea and that the choice of meals at teatime has had to be reduced as the staff do not have sufficient time Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 21 to spend in the kitchen. The manager has discussed this matter with the proprietors and they are looking at ways to address the problem. There were sufficient staffing levels on duty at the time of the inspection visit. Residents spoken with all described the staff as very friendly and supportive, several said, “ They cannot do enough for you”. Nine staff had completed a National Vocational Qualification (NVQ) level 2 or 3 in care. In discussion with the manager they stated that two staff are going to commence NVQ training in September 2006 with plans for another one to undertake this training in the near future. The home has exceeded the National Minimum Standard with over 50 of the staff attaining this qualification. Three staff files were audited which included the two most recently employed staff. It was evident from information provided that the two recently employed staff had been employed prior to receipt of Protection of Vulnerable Adult (POVA) checks. Both files had POVA first letters, which had been received at the home following commencement of employment. The manager explained that they had had telephone confirmation from the umbrella company responsible for these checks and that these staff were under constant supervision from her at all times whilst awaiting the POVA and that nobody had been put at risk. At the last inspection there was a requirement made that staff must not commence employment within the home until all suitable checks have been completed. The home must not employ a person until the POVA first letter has been received. There was evidence of Criminal Record Bureau checks having been undertaken, and two references had been received and a comprehensive application form which had a detailed work history section. None of the three staff files contained identification as required in schedule 2 of the Care Homes Regulations. This matter was also discussed with the manager, who stated that they always saw evidence of staff’s identification but had not realised that they should keep copies, as the previous owner who had trained them did not tell them this. There was evidence of certificates of training in three staff files audited. Two recently employed staff had undertaken induction training. In discussion with the manager they stated that training needs are identified via observation of practice, supervision and yearly appraisals of staff. Two staff confirmed that they have received mandatory training, which includes, health and safety, fire safety, food hygiene, manual handling and infection control. The manager explained that adult abuse awareness training is also going to become mandatory. Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems in place developed by a competent manager. EVIDENCE: The manager is skilled and competent to manage the day-to-day operations of the care home, and possesses a National Vocational Qualification (NVQ) level 4 in care and The Registered Managers Award. (RMA) The manager supports the ethos of lifelong learning and is committed to her professional development and that of the staff team. The manager is supported by two deputy managers and has learned how to delegate tasks to them. There was evidence on staff files that supervision is provided at least six times a year. In Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 23 discussion with staff one found supervision useful whilst another felt that the manager does not always resolve issues discussed. There has been an improvement in the home’s quality assurance systems since the last inspection. The home has introduced residents’ meetings, which are usually held three monthly. Minutes of the residents’ meetings are taken and records kept. There was evidence that the home had consulted with relatives/visitors, sending out 20 questionnaires. Seven completed questionnaires were returned and the home has provided feedback of the survey, which showed that in general people were very satisfied with the service being provided at the home. The manager also undertakes three monthly audits within the home. The proprietors have developed a maintenance programme to improve the home’s environment. The programme of renewal has been implemented and improvements should continue well into 2007. The home has a policy and procedure for the safe keeping of residents’ monies. In discussion with the manager they stated that three residents like to manage their own finances, whilst others have money in safekeeping. All monies are kept individually in the safe, records of income and expenditure is logged and one resident’s monies was checked against records and found to be accurate. In discussion with one resident they stated that they prefer the home to look after their money and they just ask for it when they need some. There was evidence that residents had lockable facilities available for the safe keeping of monies in several of the bedrooms. A tour of the property was undertaken and the home was found to be clean, comfortable and generally safe. The staff team have all had relevant training in the area of health and safety. In discussion with two staff they were able to demonstrate that they knew the home’s fire safety procedures. Fire systems are checked on a weekly basis and records are kept. In discussion with the manager they mentioned that the home is going to have the gas supply upgraded from a domestic to commercial supply. There was evidence that the home has gas and electrical appliances inspected and serviced regularly. The kitchen has been fitted with a new cooker, dishwasher and fridge since the last inspection. The cook explained that there had been problems with the new fridge, as it was not reaching the appropriate temperature for keeping Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 24 food at the correct temperature. A replacement fridge was delivered the day before the inspection visit and the cook stated they were experiencing the same problems. The manager is dealing with this issue as a matter of urgency. The kitchen fittings are showing signs of wear and tear and require repair or replacement. A drawer facia is missing from one drawer. A second drawer has a broken facia, edging of work surface next to cooker is damaged. There was also damage to kitchen cupboards. This is a health and safety concern and requires attention to prevent the risk of spread of infection. The manager has undertaken a generic risk assessment of potential hazards in the home and action has been taken to minimise these. All accidents and incidents are reported appropriately and CSCI are notified of serious incidents. The hot water supply to sink basins in residents’ bedrooms is not thermostatically controlled, however there are warning signs to alert residents and staff to take care. In discussion with the manager they stated that staff usually assist residents with the drawing of water. As part of the home’s improvement plans the proprietors are considering fitting mixer taps to all hand basins, which will be thermostatically controlled. Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 26 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 OP19 Regulation 23 2 (d) Requirement Timescale for action 30/11/06 2 OP29 19 3 OP29 19 (1) (b)(i) sch 2 23 (c) 4 OP38 You are required to redecorate the bedroom, which has damaged paintwork, which should have been redecorated whilst vacant. Staff must not commence 30/11/06 employment within the home until all suitable and appropriate checks have been completed. This was a requirement from the previous inspection dated 07/12/06. You are required to obtain and 30/11/06 keep records of staff identification, which must include photographic identification. You are required to repair or 30/11/06 replace kitchen units as listed in the report. Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 27 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 OP15 Good Practice Recommendations Ensure that there are sufficient food provisions in the home to meet with residents’ preferred choice at meal times and continue to consult and listen to residents’ requirements. Waxham House DS0000064160.V299398.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA National Enquiry Line: 0845 015 0120 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. 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