Inspection on 01/08/06 for WCS - The Limes

This inspection was carried out on 1st August 2006.

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

WCS - The Limes 16/06/07

WCS - The Limes 02/03/06

WCS - The Limes 25/09/05

WCS - The Limes 27/01/05

WCS - The Limes 02/09/04

WCS - The Limes 30/03/04

WCS - The Limes 14/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE WCS - Limes, The Alcester Road Stratford On Avon Warwickshire CV37 6PH Lead Inspector Deborah Shelton Key Unannounced Inspection 1st 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 WCS - Limes, The DS0000004268.V304474.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. WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service WCS - Limes, The Address Alcester Road Stratford On Avon Warwickshire CV37 6PH 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) 01789 267076 01789 414627 Warwickshire Care Services Limited Miss Lesley Jane Anderson Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2nd March 2006 Brief Description of the Service: The Limes is a home for twenty-seven older people. It was previously a Local Authority home, but was transferred in 1992, along with a number of other homes, to Warwickshire Care Services, a voluntary sector organisation. The Limes provides personal care to twenty-four permanent service users and has three rooms, which are reserved for short stays. The home also caters on weekdays for up to sixteen-day care service users. Accommodation is on two floors. There is a lounge/dining area on the ground floor and separate lounge and dining areas on the first floor. Nineteen of the bedrooms have en-suite facilities. The home is very close to the town centre of Stratford-upon-Avon. It has parking on site and is near to the train station. The currently weekly charge for accommodation, board and personal care is £415 - £540. Additional charges are made for private chiropody, hairdressing, personal items, toiletries and newspapers/magazines. This information was provided by the manager on 15 August 2006. WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following are the findings of an unannounced inspection visit that took place between the hours of 09.40am and 6.40pm on Tuesday 1 August 2006. The care manager was on duty along with four care assistants, the housekeeper, housekeeping assistants, the cook and an administrator. The manager was taking annual leave and was not present at the inspection. Twenty two permanent residents and two short stay residents were living at The Limes; ten people were spoken to about their experiences of life at the Home. The inspection process also included case tracking the daily life of certain residents at the Home, this involved reading records, talking to the residents, looking at their environment, discussions with staff on duty and reviewing staff training records to ensure training is provided to meet resident’s needs. Some of the documentation was looked at in the lounge, this enabled the inspector to see residents in their usual surroundings and see the interaction between staff and residents. What the service does well: The atmosphere at the Limes was relaxed and friendly. Residents were happy wandering about the Home and chatting amongst themselves and with staff. Staff spoken to said that they all work well as a team and are able to speak to the manager or care manager whenever they need. Residents said that they were happy at the Home and apart from a few comments regarding lack of activities and repetitive food received from a small few residents all other comments were positive. Some of the comments raised are detailed below: “you always have a choice in everything that you do” “the food is excellent, there is a big choice and you get plenty” “I do what I want, I wouldn’t change anything” “staff are great they work really hard” “it is not your own home but it’s as good as it could be” WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 6 “Its great here, nothing could be better, the staff are nice, there is nothing else to say, everything is good” Staff interacted well with residents and visitors to the Home. Operations in the Home are well organised with the support of an effective management and administrative team. 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. WCS - Limes, The DS0000004268.V304474.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 WCS - Limes, The DS0000004268.V304474.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): 3, standard 6 is not applicable to this Home Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Pre admission assessments provide staff with the information they need to develop a care plan to meet resident’s individual needs. EVIDENCE: The care plan of the most recently admitted resident demonstrated that sufficient information is gathered prior to agreeing a placement at the Limes. The manager confirmed that potential residents and their relatives are involved in the pre-admission assessment as much as possible. Care plans provided by Social Services also form part of the information used during the assessment process. Standardised documentation is used to record details. Health and personal care needs are then recorded in an initial plan of care, which is available prior to the resident’s admission to the Home. WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 9 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plan programmes and risk management strategies are in place to meet the assessed and changing needs of residents. Residents have good access to a wide range of health professionals which results in their healthcare needs being met. Systems and practices regarding storage and administration of medicine are good. The Home’s policies and procedures for dealing with medicines protect residents from risk of harm. Residents are treated with respect and their rights to privacy and dignity are maintained. EVIDENCE: Five care files were reviewed at this inspection. This included the care file of the resident most recently admitted to the Home. WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 10 Care files were in good order and up to date. Standardised documentation is used to record information. Sufficient details were recorded to enable staff to meet the health needs of those under their care. As well as details of health and personal care, care files record choices regarding personal care being provided by a male or female carer, the resident’s preferred terms of address, religious and social needs. A requirement was made at the last inspection regarding daily records. Some records reviewed were still not satisfactory. One care plan recorded that the resident likes to be checked during the night. Daily records stated “appears to have slept well, no calls”, this does not demonstrate that the resident has been checked on during the night. Other daily records stated 5am – “cup of tea will be offered at 7am”. This is also not acceptable, as the record does not demonstrate that this actually happened. There is sufficient documentary evidence to demonstrate that external professionals are contacted to provide advice and support as necessary. Details of medical visits are recorded as well as visits made by District Nurse, Chiropodist and optician. Each care file contained bathing records which also recorded when staff have applied cream to a resident’s skin. The records in one file had not been completed since June 2006. All residents appeared well groomed on the day of inspection, hair was neatly brushed and residents were dressed appropriately for the time of year. One care file contained a catheter check sheet that was not up to date and had only been completed on an ad hoc basis. The care plan gave staff adequate instruction regarding the action to take to maintain the catheter. An inventory of personal belongings was also available in each file. There was no documentary evidence to demonstrate that residents are involved in the care planning process. The manager stated that residents do not sign their care plans, however staff sit with residents and discuss care issues when they are updating the care plan. Two residents spoken to about care planning confirmed that they had not seen their care plan but had not wanted to. They said that staff sit with them on a regular basis and chat to them about their care, they said that the staff make notes in a folder which they understood was their care plan Care files also contained details of activities undertaken, these were not completed on a regular basis and records do not demonstrate that regular activities take place. WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 11 Those who wish are able to self medicate. Care files recorded the medications that are to be self-administered. Residents have signed a form to say that they wish to self medicate. Appropriate storage facilities are provided. The Care Manager undertakes a weekly medication audit. Controlled medications were checked and found to be recorded and stored in a satisfactory manner. Each medication administration record (MAR) contained a photograph of the resident. MAR charts were up to date and had been signed appropriately. Medication cupboards were clean, tidy and did not contain excess stock. It was a requirement of previous inspections that eye drops contained the date of opening and expiry date. These dates were recorded on the eye drops seen at this inspection. Staff were seen to interact well with residents throughout the inspection. Staff knocked on bedroom doors prior to entering and were patient and kind to residents. Resident’s said that staff respect their privacy and dignity at all times. WCS - Limes, The DS0000004268.V304474.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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lifestyle experience in terms of social and leisure activities does not meet the expectations of all residents. Residents are able to maintain contact with family and friends as they wish and were happy that they still had some control over their lives and the choices that they make which improves their sense of wellbeing. Meals are well presented, wholesome and provide residents with a nutritious and balanced diet. EVIDENCE: Records regarding activities undertaken were not sufficiently maintained. Care files seen contained details of activities but these were not completed on a regular basis and were not up to date. Notice boards recorded events that take place on a Saturday and Sunday i.e. a Sunday Roast, Film afternoon with buffet after. Staff said that relatives are invited to join in these events. WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 13 A member of care staff also has dedicated time (4.5 hours per week) to work as the activity organiser. Activities were taking place on the day of inspection. Female residents were having their nails manicured and were pleased to show their nicely painted nails. The activity organiser said that she was going to bath a new resident and give her a massage to try and settle her into the Home. Other residents were having their hair washed and set by the visiting hairdresser. Ten residents were spoken to about their experiences of life at the Limes, two of which were staying for a short period of respite care. Residents said that you have choices in everything. There is a choice of meal, times for getting up and going to bed, you are able to go into the day care unit if there is space available to join in their activities or just sit and chat to people. Some residents confirmed that there is enough to do in the day, activities such as exercise to music and quizzes take place. Other residents preferred to spend a majority of their time in their room and some said that there was not really enough to do in the day. A large majority of residents were satisfied with the social and leisure activities that take place at the Home. All residents praised the staff saying that they are friendly and kind. Residents religious needs are met by visiting clergy, residents are also able to visit a local church if they prefer. Residents meetings are held on a regular basis. One resident said that he regularly attends these meetings as they are a good way to express his views. Minutes of resident’s meetings are given to each resident and a copy is kept on the notice board. All residents said that visitors are made to feel welcome, are offered drinks and invited to join in activities. Residents said that they are able to see visitors in their lounge, their bedroom and some go out with their visitors. One resident commented that his “family visit regularly, they are always made to feel welcome and offered drinks, staff are always kind to them”. Residents are given a choice of two main meals on a daily basis. Each lunchtime meal starts with soup, a choice of two main meals or salad alternative and a choice of deserts. The Housekeeper is in charge of catering and domestic staff. A lot of work has taken place to try and meet the nutritional needs of residents. A snack box has been put in each resident’s bedroom with an assortment of individually wrapped snacks (to maintain freshness). The Housekeeper said that staff regularly check snack boxes to refill or remove items that are out of date. The kitchen was clean and hygienic. Records are kept of fridge and freezer temperatures, food probe records and cleaning schedules. WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 14 Residents said that they enjoy the homemade food and a majority were satisfied with the meals provided. One resident said that the meals can be a bit repetitive, another said that they prefer plain English cooking. During the luchtime meal residents were overheard talking about some sausages that they had eaten the day before which were tough to chew. The Care Manager later confirmed that she had spoken to the cook about this and had discussed a different way of cooking the sausages to ensure that they were not tough again. WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are handled objectively and service users are confident that their concerns will be listened to and acted upon. Policies and procedures concerning the protection of vulnerable people are appropriate and residents are protected from harm. EVIDENCE: No complaints have been received by the Commission for Social Care Inspection since the last inspection visit. Complaint logbooks are kept on each unit at the Home with a separate book being kept in the kitchen. One complaint has been received by the Home, details of the concerns were recorded in the logbook along with the action taken to address the complaint. Details were recorded in a satisfactory manner. A copy of the complaint policy is on display on notice boards throughout the Home. No adult protection issues have been raised at this Home. All staff have criminal records bureau checks undertaken and staff have recently undertaken protection of vulnerable adults training. Resident’s finances are kept in a satisfactory manner. WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this Home is generally well maintained providing an attractive, hygienic and homely place to live therefore improving the quality of life for residents. EVIDENCE: At the last inspection of the Home concern was raised regarding the cats living in the manager’s office. There was no evidence that these cats now live in the office. The Care Manager said that the cats are mainly outside of the Home and their beds are now in the conservatory. The cats were seen wandering around the garden and residents were enjoying watching them and were chatting about how the cats had grown. Another issue raised at the last inspection related to the bath chair which was corroded, the enamel was coming off the bath which was noted as being dirty. The Radiator cover in this bathroom was also dirty, communal toiletries were WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 17 available as well as a communal electric shaver, which was in need of cleaning. These issues have now been addressed. A new bath has been purchased with bath chair these were clean and in good working order. The radiator cover in this bathroom was also clean. No communal toiletries were noted in any bathrooms and the care manager confirmed that communal toiletries are no longer used and the electric shaver has been thrown away. The laundry was clean and there was no backlog of items to be laundered. A new washing machine was waiting to be plumbed into the automatic dosing system that provides the cleaning chemicals. All other equipment was in good working order. Resident’s commented that their laundry is taken away on one day and returned the next. They reported that they receive an excellent laundry service. The kitchen was clean and hygienic appropriate records are kept regarding hygiene and food safety. The report of the last environmental health inspection was seen, no recommendations were made. Bathrooms and toilets were clean and no unpleasant odours were noted. Sluice areas were checked, these are locked when not in use. The first floor lounge is currently being used as a hairdressing salon, residents said that they enjoy sitting on the walkway between the old and new building. Residents call this area “the bridge” and were seen sitting comfortably and chatting amongst themselves. Some residents were having a manicure. A new carpet has been fitted in the ground floor corridor and in bedrooms 2 and 19 since the last inspection. All other carpets seen were clean and in good condition. All bedrooms seen were clean and hygienic and no unpleasant odours were noted. Rooms contained adequate furnishings that were in a good state of repair. They had been personalised with ornaments and pictures. Residents said that the domestic staff are friendly and they do a good job as the Home is always clean and tidy. WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home is well staffed with adequate numbers and skill mix available. The staff team are enthusiastic and well trained. Staff recruitment and selection procedures ensure that only those individuals deemed to be suitable are employed to work at the Limes. EVIDENCE: A copy of the duty rotas was taken for review, staff work set shifts between the hours of 7.30am – 2.30pm, 2.30pm – 9.30pm and 9.30pm – 7.30am. Four care staff are on duty during the day and two at night. The manager and/or care manager are also on duty along with domestic and catering staff. On the day of inspection sufficient numbers of staff were on duty to be able to meet the care needs of residents. Twenty-five staff are employed to care for those living at the Limes. Currently 10 of these have completed National Vocational Qualification in care (NVQ) level 2 training, six have progressed and obtained level 3 (eight in total have NVQ level 3). Currently the Home does not have 50 of care staff NVQ qualified. However a further 13 staff are now undertaking this training. WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 19 During discussions with residents it was noted that all staff are helpful, friendly and kind. Residents felt that there is enough staff on duty and that they always come quickly when call bells are used. Some of the comments made are detailed below: “the staff are all lovely and very kind” “staff are always kind to my visitors” “staff are helpful and polite, they knock on doors before they come in to your room” “staff are always polite” Four staff files were reviewed and found to contain all information as required by standards. Each file contained copies of application forms, references, evidence that criminal records bureau checks have been undertaken, training details and supervision records. Files were in good order and information could be found easily. Criminal records bureau documentation is kept at Warwickshire Care Services Head office. The Home does not keep copies of birth certificates or passports, however these documents have been seen by the manager or care manager. All staff have undertaken the induction training provided by the Home. Induction training is in line with the requirements of the Skills for Care Training. WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The quality management systems in place ensure that the home is run in the best interests of the residents. Appropriate systems are in place to safeguard residents financial interests. The policies and practices regarding safe working ensure that resident’s health, safety and welfare is promoted and protected. EVIDENCE: The manager was on annual leave at the time of inspection. The inspection process was conducted with the assistance of the Housekeeper and the Care Manager. There have been no changes to the management at this Home since WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 21 the last inspection visit. Management systems and practices work well and issues identified during inspections are addressed in a timely manner. Quality assurance questions form part of the care planning process. One quality assurance question is asked of each resident on a monthly basis. The results of these questions are collected and sent to Warwickshire Care Services Head Office. When an issue is identified the Care Manager must record the action she has taken to rectify the problem. Residents meetings are held approximately every eight weeks. Minutes of the meetings are on display on notice boards around the Home. Some residents commented that they are glad that they have the opportunity to air their views. The care manager discussed various quality assurance practices that take place, for example either the manager or care manager eat with residents on a regular basis to discuss meals with the residents and to test the quality of the food. Each member of staff has two “observed practices” each year. Regular audits take place of care plans, accidents, medication and resident’s spending money records. There are adequate systems in place to ensure that the quality of the service provided meets the needs and expectations of those who live at the Limes. Resident’s spending money records were reviewed. Residents are able to look after their own money if they wish. Records seen were in good order and up to date. Administration staff are responsible for receiving and issuing funds. Money is stored appropriately. A sample of maintenance records were reviewed to evidence whether the health and safety of residents and staff is maintained. Fire alarm system records were reviewed and found to be up to date. Portable electrical appliance tests are undertaken on an annual basis and a legionella risk assessment is available, water chlorination takes place as necessary. Training records demonstrate that staff receive regular mandatory training. First aid, fire and manual handling training is all up to date. Some staff require update training regarding food hygiene. WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A 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 2 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 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Daily entries must only record actions that have taken place and not those which are planned. Daily records should be linked to care plans and demonstrate the actions that staff are taking to deliver the prescribed care. 2 OP12 16(2)(m) (n) 09/10/06 An activity programme must be developed following consultation with the residents about their social and leisure interests Activity programmes must be available for review and evidence must also be available to demonstrate that activities take place which are suited to the wants and needs of Service Users. The registered provider must ensure that a minimum of 50 of care staff on duty have a National Vocational Qualification in care. 09/10/06 Timescale for action 09/10/06 3 OP28 18(1)(a) (c) WCS - Limes, The DS0000004268.V304474.R01.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 2 Refer to Standard OP7 OP7 Good Practice Recommendations The manager should ensure that records regarding personal hygiene, catheter care are kept up to date. Care files should be signed by the residents or their representative to demonstrate their involvement in the care planning process. The manager should ensure that food hygiene training is up to date for all staff. 3 OP38 WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Coventry & Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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. Extracts may not be used or reproduced without the express permission of CSCI WCS - Limes, The DS0000004268.V304474.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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