Inspection on 29/12/05 for WCS - Westlands

This inspection was carried out on 29th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 - Westlands 10/10/06

WCS - Westlands 28/07/05

WCS - Westlands 03/11/04

WCS - Westlands 26/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE WCS - Westlands Oliver Street Rugby Warwickshire CV21 2EX Lead Inspector Mrs Suzette Farrelly Unannounced Inspection 29th December 2005 09:30 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 - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 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 - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service WCS - Westlands Address Oliver Street Rugby Warwickshire CV21 2EX 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) 01788 576604 01788 535553 Warwickshire Care Services Limited Care Home 38 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (27) of places WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th July 2005 Brief Description of the Service: Westlands is a three-storey purpose built care home. The home is currently owned and managed by a voluntary organisation, Warwickshire Care Services. Westlands underwent a major refurbishment in 1998. The home is located close to Rugby town centre, bus and railway stations and is located within a community, which provides local services such as shops, public houses, restaurants, coffee bars and clubs. Accommodation is located on three floors. Each floor has one lounge and a dining area with integral kitchenette. All bedrooms are single some have ensuite facilities. Service users can furnish and redecorate to their own taste if they wish. The gardens are attractive, well maintained and accessible. There is a variety of garden furniture including sun umbrellas and tables. A ramp allows easy access to the patio area. The home provides both long-term residential care for 38 frail older people, and a day care facility, which accommodates up to eight older people. . WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of 2005/06 and took place over one day from 11:30 until 18:30. The staff co-operated fully and the clinical manager and support manager were present throughout the inspection. Various standards were assessed and a tour of the home took place. Records concerning residents, staff and the maintenance of the home were seen and examined. Discussions took place with residents and staff. No relatives were seen during this inspection. The home has had four managers within the last twelve months, which has led to changes in leadership, guidance and direction for the staff. The home is without a manager at this time and is managed between the clinical manager and support from a manager who works at another Warwickshire Care Service’s home. This had resulted in poor application of the policies, procedures and systems available to the home. What the service does well: What has improved since the last inspection? WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 6 New carpets and re-decoration of bedrooms and corridors had continued. Further rooms and one corridor still require decorating and this is planned. There is now better use of the communal space. An extra lounge has been created from a previously unused communal space, the purchase of new televisions now ensures that residents have more choice on how and where they spend their time. 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 - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 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 - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 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, 4 & 5 Residents are admitted to the home without his/her needs being fully assessed by the home and are not assured that their needs could be met. Prospective residents, their family and friends are given the opportunity to visit prior to admission to assess the quality, facilities and suitability of the home. EVIDENCE: Four residents profiles were examined and six residents spoken to. It was noted from the records that there were no pre-admission assessments available. This could result in poor care provision on admission to the home. Social Service assessments and care plans were seen in the Care Office, these are not available in the residents’ profiles. A ‘Life History’ sheet was available in the residents’ profiles and this gave information concerning the residents’ likes, dislikes and important events throughout their lives. WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 9 There were no written records to indicate that care plans had been developed prior to admission to ensure that the needs of the resident could be met at the point of admission. There were no written records to indicate that residents, their families and friends had been offered the opportunity to visit prior to admission. However, one resident spoken to had visited prior to admission and a further three residents said that their relative had visited and fed back the information. Staff training in specific areas such as dementia care and the management of artificial feeding has still not been completed. This lack of training may impact on the quality and consistency of care afforded to the residents, resulting in poor practices, which may put the residents at risk of harm. WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 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 The residents’ health, personal and social care needs are mostly met however the care plans are insufficient to demonstrate the residents’ needs. Residents are not fully protected by the policies and procedures for the management of medicines. EVIDENCE: Four resident profiles were examined and it was found that there is an in-depth assessment process covering all the Activities of Daily Living that clearly states where residents need assistance. The information from these assessments are not clearly set out in care plans allowing staff to easily determine the care required. A ‘Care Summary’ was examined in all four profiles; this gave simple instruction on the usual daily routine but failed to discuss issues of concern, such as poor nutrition, the risk of pressure damage and challenging behaviours. WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 11 This approach to care relies on the staff knowing the residents and having good verbal communication systems. The risk assessments seen clearly identified changing care needs; these were not reflected in the care plans. The clinical manager is aware of this and is planning to work with the staff to ensure that the care plans are up to date and contain suitable information. The resident or their representative signed monthly assessment sheet and a quality question was also answered in relation to the service provided by the home. The staff had failed to make any comments either related to the care provided nor record any comments made by the resident and/or their representative. Nutritional risk assessments were examined and these addressed all areas required. On one unit the residents had not been weighed for up to three months. On the Dementia Care Unit residents had been weighed monthly. A resident who had lost 1.6kg in six months had been referred to the GP and prescribed fortified drinks. This resident was also referred to the dietician for advice. This was clearly recorded in the risk assessment. There was no care plan to guide staff on the actions to be taken. Systems for the management and administration of medication was assessed and the following were discussed with the clinical manager and support manager: • • • • Not all administration of medication is recorded on the Medication Administration record. Control Drugs were not kept in the appropriate cupboard. The Control Drug Register was poorly maintained. Policies and procedures related to the management of medicines were not up to date and the registered provider must ensure that they meet with the current legislation and guidance from the Royal Pharmaceutical Society. There has been some improvement since the last inspection; however, these areas must be addressed to minimise the risk of harm to the residents. WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 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 The residents lifestyle experience part matches their expectations and preferences partially satisfying their social, cultural, religious and recreational interests and needs. Residents are able to maintain contact with their family and friends and the local community where they wish. Residents are assisted to maximise choice and control over their lives. The residents receive an adequate diet in surroundings that are pleasant and sociable. EVIDENCE: The four resident profiles examined had very good information about the residents’ past lives and their interests and hobbies. The staff have not used this information to develop either individual or group activities. The support manager is aware of this. The development of activities has not moved forward in part due to the continual change of the manager of the home. WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 13 During the inspection it was seen that staff give residents a choice when ever possible, concerning such things as where they spend their time, food they eat, and what they wish to do. One member of care staff said that all staff tried to do ‘activities’ but this ‘could only happen if there were enough people on duty’. Another member of staff stated that all activities were ad-hoc and it depended on the staff member on duty and their enthusiasm and abilities. There are no restrictions on visiting and the residents can see their relatives and friends in any of the communal areas or their own rooms. At present there is no written information about visiting. It is advised that this is developed to ensure that residents, relatives and others are fully aware of their rights. There are limited community links with the home. Five residents spoken with stated that they had recently been out in the last week, either to visit family or to shop. The home assists and encourages the residents to make choices related to their own lives. The home manages a small amount of personal monies and the residents can access this money at any time. The accounts showed that the residents often ask for money so they can buy what they wish. One resident stated that it was like being at home, except that there were friendly people around to help where needed. The main kitchen was seen and it was disorganised and dirty. The support manager stated that they had recently sacked the cook for not carrying out their duties and were in the process of advertising for a replacement. Records to demonstrate that the fridge and freezer temperatures are checked and that the daily, weekly and monthly cleaning schedules are completed were unavailable. There were no suitable menus, the menus being used were from summer 2005 and the support manager stated that this was not always followed. Residents spoken with stated that they enjoyed the food and there was always sufficient and the weights of residents suggest that they eat enough food to sustain their present body weight. Each unit has a small kitchen area that is maintained by the unit staff. These areas were clean and organised and there was a selection of snack foods available. Drinks were offered at frequent intervals and staff were seen making drinks for the residents when requested. WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Residents are largely protected from abuse by the management and the policies and procedures of the home. EVIDENCE: Policies and procedures related to the recognition of abuse and actions to be taken in the event of alleged or actual abuse were examined. Some areas were out dated and the support manager stated that new policies and procedures were being made available in the near future from Warwickshire Care Services. The Whistle Blowing Policy, which informs staff of their obligation to share information with the manager regarding poor or dangerous practice, was also examined. This was found to be good and ensured that the rights of all involved are met. There is also a suitable policy and procedure for dealing with verbal and aggressive behaviour from residents. The clinical manager stated that training in the recognition and management of Adult Abuse was to commence early in 2006. WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 15 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): 21, 22, 24 & 25 The residents live in safe and comfortable surroundings with sufficient equipment to ensure that they have maximum independence. EVIDENCE: There are three separate units in the home; each unit has three en-suite bedrooms consisting of a toilet and hand washbasin. The remaining 10 bedrooms are situated close to communal toilets. Each unit has a full assisted bath and shower room. The residents have access to all areas of the home via the shaft lift or stairs. There is access to a secure garden at the rear of the property via doors on the lower ground floor. Grab rails were seen in the corridors, toilets and bathrooms and mobility aids were seen being used by the residents. WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 16 All bedrooms and communal areas have call bell facilities and during the inspection these were used by residents and staff answered these within less than two minutes. Four bedrooms in each unit were seen; six bedrooms were occupied at the time of the visit. It was confirmed through discussion that in all cases the resident had requested to stay in their room or had decided to take a rest. The bedrooms were reasonably decorated, and it was evident that some had recently been up dated. The residents spoken to were happy with their personal space and stated that they had all they needed and were able to bring personal belongings with them at the time of admission. All door have suitable locks and residents can have a key if they wish. It was seen that some carpets in bedrooms and communal areas had been recently changed and further carpets are to be changed in the near future. The home has good views of the garden and surrounding green areas from large windows in the lounge areas. The bedroom windows are at a sufficient height to allow the resident a view when seated. The overhead lighting is domestic in nature and sufficient throughout the home. There is also emergency lighting through out. Hot water is stored at 60OC and pre-set valves are used to ensure that the water is close to 43 OC to prevent scalding. WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 17 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 Residents’ needs are not always met by the numbers and skill mix of staff, which could result in poor provision of care. Staff training is insufficient to ensure that the residents are in safe competent hands at all times. Recruitment of staff is insufficient to ensure that all staff employed are safe to work with vulnerable adults. EVIDENCE: The staffing levels were discussed and it was found that at times there is insufficient staff on duty to ensure that the needs of the residents are met. The management must ensure that gaps in the duty roster are filled and that staffing levels do not fall below the agreed standard. The duty roster showed that the numbers of staff on duty varied considerably and the support manager stated that this was due to past agreements with staff. They are aware of the situation and have started to discuss changes in shift patterns with the staff. Each month the support manager completes a monthly audit of dependency needs of the residents and the number of staffing hours available and required to ensure that there are sufficient staff employed. Action plans are drawn up to address short falls of staff in comparison to residents needs. WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 18 There is one laundry person and three housekeepers who work a variety of hours. The care staff are allocated time to assisted with the laundry when this area is not covered during the week. Ten staff are presently studying for a National Vocational Qualification in Care. Training records were unavailable and the clinical manager was unable to state accurately the number of staff who are qualified. Six staff files were examined and it was noted that although there are robust procedures for employing staff this is not always adhered to. Some staff had been employed before references, Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks had been received. This has result in the home dismissing one member of staff for poor working practices, which had also occurred in their recent past employment elsewhere. Two staff did not have CRB or POVA checks available on record. The records examined were untidy and poorly organised. This made finding information difficult. There is an induction programme available. There was no evidence in the staff files to indicate that this had been utilised and the clinical manager stated that they are looking at the programme and in the process of developing a more complete programme that will cover induction, foundation and role specific training. WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Residents’ live in a home that does not have a permanent manager and the leadership and supervision of staff is poor, which could result in mediocre experiences and insufficient health care of residents. EVIDENCE: The home has a clinical manager who is supported at present by a registered manager from another home run by Warwickshire Care Services. Interviews have taken place to find a suitable manager but no appoints have been made. The home has had four changes in management in 12 months and this has resulted in areas of management responsibilities being neglected such as training, supervision and employment of staff. There is a suitable quality assurance and monitoring system in place that enables consultation with the residents, relatives, staff, GPs and district nurses. Due to the lack of a manager and frequent changes areas that require improvement have been neglected. WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 20 The The and and administrator handles small amounts of personal monies for the residents. management of these is very good and the records are well maintained easy to follow. Record of all incoming and out going monies is maintained receipts are available. Policies related to the management of finances are required. Due to frequent changes in the manager, formal supervision of staff has not been consistent. This is recognised by the clinical manager and a meeting has been set up for January 2006 to organise supervision with the staff. Warwickshire Care Services policy is for 12 unit meetings; two observed practices and two personal supervision periods for all care staff during a 12month period. Records concerning the maintenance and service of equipment in the home were up to date. These were disorganised and many certificates and paper work were not filed in the designated places. It took the housekeeper and clinical manager some time to locate all the paper work requested. There are some generic risk assessments concerning the environment. The clinical manager must ensure that these are reviewed and further risk assessments devised if required. WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 21 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 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X 3 3 x 3 3 X STAFFING Standard No Score 27 1 28 1 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 1 x 3 WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 22 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 OP1 Regulation 4, 5 Requirement The Statement of Purpose and Service User Guide must be reviewed. A copy of the completed documents are to be forwarded to the Commission. (Outstanding from 31.03.04) 2 OP3 14 S3 The registered provider must ensure that there is written evidence that all residents are fully assessed prior to admission to ensure that all their needs can be met by the home. The registered provider must ensure that all staff on the dementia unit receives suitable training in dementia care. A copy of the training programme must be provided to the Commission. (outstanding from 30.11.04) 4 OP7 15 The registered provider must ensure that each resident has a care plan. 31/03/06 28/02/06 Timescale for action 31/03/06 3 OP4 18 31/03/06 WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 23 5 OP7 15 S3 Care plans must set out in detail the action needed to be carried out to ensure that all aspects of the health, personal and social care needs of each resident is met. Care plans must be up to date and reflect the current needs of individual residents. These must be reviewed monthly as a minimum. 31/03/06 6 OP7 15 31/03/06 76 OP8 18, 17 The registered provider must 28/02/06 ensure that staff competence for the management of PEG’s is assessed and records kept. Responsibilities and accountabilities must be clarified with the Primary Care Trust and agreement to care staff administering feeds and medications via this route sought from the resident. (Outstanding from 28.07.05) 8 OP8 17 The registered provider must ensure that care plans regarding pressure area care and pressure area prevention is current and that any action taken/outcomes are recorded. (Outstanding from 30.01.05) 28/02/06 9 OP99 13 The registered provider must ensure that all Control Drugs are stored appropriately and that the Control Drug Register is maintained at all times. New Control Drug Registers must be purchased for each unit. 28/02/06 WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 24 10 OP9 13 The registered provider must review the systems for the management and administration of medications. Medicine administration records must be accurately maintained and the correct codes inserted. (Outstanding from 30.11.04) 28/02/06 11 OP9 18 13 Staff responsible for administering medications must receive training from an appropriately qualified person. A timed action plan for the achievement of this must be forwarded to the commission. (Outstanding from 28/07/05) 28/02/06 12 OP12 16 The registered provider must 31/03/06 ensure that suitable and varied social and leisure opportunities are available to residents. Specific attention should be given to the needs and capacities of those residents with dementia. The registered provider must develop suitable menus for the home in consultation with the residents. Cleaning records for the kitchen must be maintained and the kitchen area must be cleaned and an acceptable level of cleanliness maintained. The registered provider must ensure that there is sufficient staff on duty during all shifts. Gaps in staffing due to absence must be covered to ensure the care and safety of the residents. DS0000004270.V274524.R01.S.doc 13 OP15 12 30/04/06 14 OP15 16 23 28/02/06 15 OP27 18 28/02/06 WCS - Westlands Version 5.1 Page 25 16 OP28 18 S2 The registered provider must ensure that there are accurate training records for all members of staff, indicating past and present training. The registered provider must ensure that all employment checks are completed and satisfactory before offering employment to prospective staff. All staff must have a CRB and POVA check to enable them to work with vulnerable adults. 28/02/06 17 OP29 19 S2 28/02/06 18 OP30 12 18 The registered provider must ensure that there is a suitable induction / foundation programme and that this is utilised for all new staff on commencement of employment. The registered provider must ensure that there is a suitably qualified person employed to manage the home. The registered provider must ensure that issues arising from the quality assurance and monitoring process are addressed in a timely fashion. 31/03/06 19 OP31 9 31/03/06 20 OP33 24 30/04/06 21 OP36 18 19 The registered provider must 31/03/06 ensure that care staff receive supervision at least six times per year and records are maintained. WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 26 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 3 Refer to Standard OP13 OP29 OP38 Good Practice Recommendations It is recommended that information concerning visiting the visiting of residents is in writing and available to family, friends and other interested parties. It is recommended that the staff records are tidied up and put into sequential order making them easier to check for information. It is advised that the records related to the maintenance and servicing of equipment in the home is organised and easily available when required. WCS - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection 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 - Westlands DS0000004270.V274524.R01.S.doc Version 5.1 Page 28 - 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. 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