Inspection on 03/04/07 for Waynes The

This inspection was carried out on 3rd April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Waynes The 22/02/06

Waynes The 12/08/05

Waynes The 25/01/05

Waynes The 24/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Waynes The 7 Marton Road Bridlington East Yorkshire YO16 7AN Lead Inspector Diane Wilkinson Unannounced Inspection 3rd April 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Waynes The DS0000019759.V335128.R02.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. Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waynes The Address 7 Marton Road Bridlington East Yorkshire YO16 7AN 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) 01262 672351 Mrs Ann Louise Benson Mrs Ann Louise Benson Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2006 Brief Description of the Service: The Waynes is a privately owned care home that provides care and accommodation to a maximum of 30 older people; this includes respite care. The home is a detached property set in large secluded grounds. It is conveniently located for all of the main community facilities including the public transport network. The pre-inspection questionnaire provided by the registered person records that fees paid range from £286.80 to £365.00 per week and there is an additional charge for hairdressing, private chiropody, personal toiletries, newspapers and magazines. There is ample communal accommodation that includes lounges and dining rooms, plus several smaller areas where service users can have private meetings with family and other visitors. Private accommodation is located on the ground and first floors; the first floor is accessible via the use of a passenger lift. The majority of bedrooms are single and service users that share a room have made a positive choice to do so; some bedrooms have ensuite facilities. There is a ramp to the main entrance and level access to the side entrance. Internally the home has been designed to take into account service users with poor mobility. The home has its own mini-bus and the registered person endeavours to provide trips out for the service users on a daily basis. Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit is part of a key inspection and was undertaken by one inspector over one day; the site visit commenced at 10.00 am and finished at 4.15 pm. This inspection report is based on information obtained from the pre-inspection questionnaire completed by the registered manager, information received by the Commission for Social Care Inspection (CSCI) since the last inspection of the home and from the site visit on the 3rd April 2007. The site visit consisted of a tour of the premises and examination of documentation, including three care plans. On the day of the site visit the inspector spoke on a one to one basis with three residents and two relatives, as well as a member of staff and the registered provider/manager, and chatted to several other service users. Surveys were sent out to thirteen relatives and ten were returned; very positive comments were made about the care provided to service users, such as, ‘Mum always looks nice – she has her hair done there every week and she looks smart and cared for’ and ‘Her personal care is always provided for and I am always informed if there are any concerns by staff’. Surveys were sent to four GP’s and three health and social care professionals; none were returned from GP’s and 1 was returned from a health and social care professional. Comments were fed back to the registered manager (anonymously). Comments from discussions with service users and others, and respondents in surveys, will be included throughout the report (anonymously). The inspector would like to thank service users, staff, relatives and the registered manager for their assistance on the day of the site visit, and to everyone who spoke to the inspector or responded to a survey. What the service does well: Service users are assessed prior to their admission to the home and only offered accommodation if their assessed needs can be met. Service users and relatives express satisfaction with the care provided by staff at the home and speak highly of the registered person and the staff group. Service users are supported and encouraged to be as independent as possible, and to continue to live their chosen lifestyle. There is a robust system in place for the administration of medication that protects the safety and well-being of service users. Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 6 The Waynes provides a pleasant homely environment for the people who live there, with high standards of cleanliness throughout the home. The home is well organised and managed, and staff are well trained and supported. Managers and staff have a good understanding of the needs of service users. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Waynes The DS0000019759.V335128.R02.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 Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 was not assessed, as there is no intermediate care provision at the home. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are only admitted to the home following a full assessment that evidences that their current care needs can be met. EVIDENCE: The inspector examined the records for a newly admitted service user. These included a full needs assessment that had been completed by the home, as well as various risk assessments. The inspector observed in other service users’ files that a community care assessment is obtained from Social Services Care Management teams when the service user is funded by the Local Authority. The initial assessment undertaken by the home, and information gathered from other sources, is used to form the basis of an individual care plan. The registered person is advised that, following this initial assessment, Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 9 service users should be informed that their current care needs can be met by the home. Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of service users are met in a way that respects their privacy and dignity. EVIDENCE: The inspector examined three care plans; these evidenced that an individual care plan has been developed with each service user. Daily diary notes are recorded, as well as key worker notes and monthly/six monthly reviews of the care plan. Service users or their relatives attend all reviews (including monthly reviews) and records are signed by service users or their representatives – this is good practice. There are appropriate risk assessments in place for safe working practices, for example, medication, pressure care and manual handling. There is a photograph of each service user in their care plan to assist new staff with identifying individual service users. Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 11 The inspector spoke to three service users and two relatives at the time of the site visit. All spoke highly of the care provided by staff and said that medical help is sought as needed. One relative said in the survey, ‘The one time mum has been ill and a doctor called, we were telephoned straight away’. Another relative said, ‘Her personal care is always provided for and I am always informed if there are any concerns by staff’. All contact with GP’s and other health professionals is recorded. Health care professionals are involved appropriately, for example, to undertake physiotherapy assessments. Pressure care is managed appropriately and service users have been provided with pressure care equipment; they also receive satisfactory assistance with any continence needs. Nutritional screening takes place, i.e. regular weighing and the monitoring of food and fluid intake, where this is an area of concern. A care manager stated in a survey, ‘they ensured that health needs were appropriately addressed, for example, seeking advice from GP and working with district nurses and arranging for appropriate pressure relief equipment to be in place’. Any accidents are recorded individually and these records are included with care plans. The inspector observed the administration of medication; this was done in a safe and hygienic manner. Medication is stored safely and there are appropriate facilities in place for the storage and administration of controlled drugs. Some service users manage their own medication; a risk assessment is undertaken for all service users and this records their ability to self medicate storage facilities are provided to enable service users to hold medication safely. Each staff that administers medication has undertaken two training courses with a Pharmacist. It is not certain that this is accredited training but until this is confirmed, the inspector is confident that staff are suitably skilled to undertake this task. The inspector observed that service users were treated with respect and that their right to privacy was upheld. Staff were seen to knock on doors before entering and were observed to speak to service users with patience and understanding. Waynes The DS0000019759.V335128.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in activities both inside and outside of the home, and visitors to the home are made welcome. Meal provision at the home is good. EVIDENCE: The inspector observed that all care plans include details of a person’s previous lifestyle and a personal profile that records a person’s likes and dislikes. Service users confirm that they are able to exercise their choice in relation to routines of daily living including where to spend their day, where to take their meals and about taking part in social activities. In-house entertainment includes daily trips out, hairdressing, bingo, games and films. One service user told the inspector that they like to read, do crosswords, to spend time chatting to other service users and to go out for a walk. Service users are taken to church by staff at the home if they wish to attend services. Some service users went for a trip out in the home’s mini bus on the afternoon of the site visit and they told the inspector that this was a daily event. Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 13 The inspector observed that routines at the home were relaxed and that service users were supported and encouraged to maintain their level of independence and to live their chosen lifestyle. Several service users had a visitor on the day of the site visit and the inspector observed that they were made welcome by staff. One relative recorded in the survey, ‘Mum always looks nice – she has her hair done there every week and she looks smart and cared for’. Another relative said, ‘My mum is always appropriately dressed’. A relative stated in response to the question ‘What do you feel the care home does well?’ ‘Allows freedom in terms of using all areas of the home and environs. There is a choice of meal and where it is served (own room or dining room)’. Service users’ rooms have been personalised to an extent chosen by them and some have brought belongings from home to decorate their room. Service users are supported to handle their own financial affairs and the home is able to refer people to advocacy services should this be required. Some service users have had a telephone installed in their bedroom so that they can maintain contact with friends and relatives, and other residents at the home. Some service users have had satellite TV installed so that they are able to watch their choice of sport and other topics of interest throughout the day. The inspector observed the serving of lunch and noted that service users had a choice of two main meals. Some service users chose to take meals in their room; one service user had a relative visiting that had lunch with them. Most service users had their lunch in one of the two dining rooms; staff provided service users with a relaxed and pleasant atmosphere so that they could enjoy their lunch at a leisurely pace. The inspector observed that service users were assisted appropriately to eat their meals. The inspector noted that service users remained in the dining room (in an area with comfortable seating) after lunch, chatting and watching wildlife in the garden. All service users told the inspector that meals at the home are very good and that there is always a choice available. One service user said, ‘the home provides good, plain meals and there is always a choice – drinks are available at any time’. Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 14 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 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users have used the complaints process and relatives state that they know how to make a complaint; both feel that their complaints would be listened to. Staff are aware of, and follow, adult protection policies and procedures; this protects service users from the potential to be abused. EVIDENCE: The inspector spoke on a one to one basis with three service users. All said that they were not aware of the complaints procedure. However, one of them did say that they met with their key worker on a monthly basis and that they would use this opportunity to raise any concerns. Six of the ten relatives that returned a survey said that they knew how to make a complaint. One relative said, ‘My mum would not hesitate to voice her own concerns if there was anything she was worried about’. Other relatives said that they had never had to raise a concern about the care provided by staff. There are appropriate policies and procedures in place and there is a complaints log to record any complaints made to the home – there was only one formal complaint received in 2006. The registered person informed the inspector that any minor complaints or concerns would be recorded in the message book – examples of this were shown to the inspector. The complaint referred to had been investigated in a more than satisfactory manner by the registered person and the complainant had been informed of the outcome. Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 15 The inspector recommends that the registered person makes every effort to ensure that service users know how to make a complaint or express a concern. There are appropriate policies and procedures in place on adult protection. The registered person and most care workers have undertaken training on the protection of vulnerable adults from abuse. In conversation with staff, the inspector noted that staff had an understanding of adult protection and whistle blowing policies, procedures and practices. Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides service users with attractive, comfortable and well maintained accommodation. Domestic staff and the laundry facilities in place ensure that communal and private areas of the home are always clean and hygienic and that service users’ clothing is clean and in good order. EVIDENCE: The home is comfortably and attractively decorated and is well maintained. The grounds are kept tidy, safe, attractive and accessible to service users and allow ample access to sunlight – lounge and dining areas have large windows/doors overlooking the garden. The inspector observed that the vinyl flooring in two toilets had started to ‘lift’ from the floor and the registered person agreed to repair these areas. The inspector also noted that a ramp connecting one floor level to another was ‘slippery’ – again, the registered Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 17 person agreed to rectify this. Staff spoken with said that they had not noticed any problems with the ramp. The premises were clean, hygienic and free from offensive odours on the day of the site visit. Domestic and housekeeping staff are employed and this enables care staff to concentrate on the care needs of service users. One relative commented, ‘The Waynes is very clean and comfortable. I could not wish for anything better for my relative’. The laundry facilities meet required standards and service users told the inspector that they are satisfied with the laundry service provided by the home. The inspector recommends that separate hand washing facilities are provided for staff in the laundry room to fully control the risk of cross infection. There is no evidence that staff have undertaken training on infection control but the inspector observed that good hygiene practice was being followed by staff – training on this topic is an area should be considered for the future. Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Well-trained staff are employed in sufficient numbers to ensure that the needs of service users accommodated at the home can be met. Recruitment practices are not robust and do not fully protect service users from the potential to be abused. EVIDENCE: The staff rota records (and the inspector observed on the day of the site visit) that there are sufficient staff on duty to meet the needs of service users accommodated at the home. There is a cook and two domestic staff on duty each day; this enables care staff to concentrate on caring duties. The staff rota does not record the role of each member of staff employed and this should be addressed. Service users told the inspector that staff respond quickly whenever they ring the call bell. The pre-inspection questionnaire completed by the registered person records that approximately 75 of care staff have now achieved a National Vocational Qualification (NVQ) at Level 2 (or above) in Care; evidence seen on the day of the site visit supported this. The registered person informed the inspector that they are currently having difficulty locating training providers for NVQ awards but that they are making further enquiries to try to secure this. Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 19 The inspector examined staff recruitment records, including those for the newest member of staff. These evidenced that satisfactory recruitment practices are not being used at the home. The registered person informed the inspector that they had been advised not to use an application form due to Data Protection issues, i.e. there should be no record of a person’s home address until a short list for interview has been decided upon. This means that there is no record of an applicant’s employment history, criminal record declaration or medical history. There is also no record of questions asked and responses given by applicants, so no record of decision making around individuals employed by the home. The registered person confirmed that staff have commenced work at the home prior to a POVA first check or CRB check being in place; CRB checks from previous employers have been accepted until a new CRB check has been received, and sometimes several weeks have passed in the interim period. The purpose of POVA first checks were explained to the registered person. References addressed to ‘to whom it may concern’ are accepted by the registered person, although these are obtained by prospective employees at the request of the registered person, rather than being obtained randomly. Training records evidence that staff undertake appropriate induction training and on-going training around health and safety issues. There is a record of core training undertaken by all staff as well as individual training records, and these include a copy of certificates obtained as a result of attending training programmes and advisory sessions. NVQ training is encouraged and supported and this has led to a high level of achievement. Most staff have attended training of safeguarding adults, health and safety and food hygiene and all staff have attended fire safety training. Some staff have attended more specialised training such as palliative care. The registered person should ensure that all staff have undertaken core training such as health and safety and first aid, and that this training is updated on a regular basis. Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well-managed and service users and others are able to affect the way that the home is operated. The health, welfare and safety of service users and staff are protected, with the exception of recruitment practices. EVIDENCE: The registered provider/manager has undertaken NVQ Level 4 in Care and has achieved the Registered Manager’s award. She is continuing her training by undertaking NVQ Level 5 and attends in-house training sessions along with the staff group to ensure that her practice is kept up to date. The inspector Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 21 observed on the day of the site visit that staff work well as a team and a relative commented, ‘The Waynes is very well organised’. There is a quality assurance and quality monitoring system in place at the home. QA audits take place regularly on topics such as infection control, medication, access to health care professionals and catering. Staff meetings are held on a regular basis and staff spoken to confirmed that they are able to raise issues and make suggestions at these meetings. The registered person informed the inspector that informal resident meetings are held. The home does not have QDS, the local authority’s quality monitoring award, but they are making enquiries about how to achieve this. Service users and others are surveyed on an annual basis and information gained from surveys is collated and actioned. The registered person informed the inspector that a new customer care policy has been adopted and that some staff have undertaken customer care training. The registered person recorded in the pre-inspection questionnaire that no monies are handled or held on behalf of service users, and this was confirmed on the day of the site visit. Service users hold their own money and lockable storage facilities are available in each bedroom to ensure safe-keeping. Service users pay for hairdressing and other services provided at the home. The registered provider informed the inspector that some service users who attend the home for respite care leave valuables in the homes safe – they put these in an envelope and they are given a receipt for the envelope. In house fire alarm tests are carried out every week and fire training/drills are carried out on a regular basis. The inspector was informed that the fire alarm system and fire extinguishers are serviced by a contractor annually. However, the current fire alarm certificate could not be located and the registered person agreed to forward a copy of this to the CSCI as soon as possible; this has now been received. Portable appliances have been tested, there is an electrical installation certificate in place, the passenger lift has been serviced on a regular basis and there is a current gas safety certificate in place. The inspector was informed that the mobile hoist and bath hoist are serviced ‘in house’ and that this has always been the case; the registered person should ensure that these appliances are serviced by someone who is qualified to do so. Staff undertake training on health and safety topics. Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 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 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19 Requirement There must be two written references that have been requested by the registered person in place prior to staff commencing work at the home. A satisfactory CRB check that has been requested by the registered person must be in place prior to staff commencing work at the home. Each applicant must complete an application form and this should be retained by the registered person. Timescale for action 03/04/07 2. OP29 19 03/04/07 3. OP29 19 03/04/07 Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 24 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 OP19 Good Practice Recommendations The registered person should rectify some minor maintenance concerns, i.e. ‘loose’ vinyl on two toilet floors and the ‘slippery’ surface on one ramp, as agreed on the day of the site visit. To control the risk of cross infection, separate hand washing facilities should be provided for staff in the laundry room. The registered person should consider organising training on infection control for staff. The role of each staff member should be recorded on the staff rota. Hoists should be serviced by someone who is qualified to do so. There should be a copy of the current fire alarm test certificate available at the home. (A copy of this has been sent to the CSCI since the day of the site visit) 2. OP26 3. 4. 5. OP27 OP38 OP38 Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 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 Waynes The DS0000019759.V335128.R02.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!