Inspection on 27/02/07 for Weald Hall

This inspection was carried out on 27th February 2007.

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

Weald Hall 04/02/08

Weald Hall 27/01/06

Weald Hall 21/09/05

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Weald Hall Mayfield Lane Wadhurst East Sussex TN5 6HX Lead Inspector Elizabeth Baker Key Unannounced Inspection 27th February 2007 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 Weald Hall DS0000064881.V323695.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. Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Weald Hall Address Mayfield Lane Wadhurst East Sussex TN5 6HX 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) 01892 782011 01892 785274 louisecoppard@crosswaystrust.org.uk www.crosswaystrust.org.uk Crossways Trust Limited Louise Coppard Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty five (25). That the care home provides personal care to older people aged sixty five (65) years or over on admission. 27th January 2006 Date of last inspection Brief Description of the Service: Weald Hall is a large detached house in the Snape valley, a short distance from the market town of Wadhurst, where there are shops, banks, library and post office. It provides care and support for up to 25 older people The home is approximately one mile from Wadhurst railway station. There are rail and bus links to Tunbridge Wells. The ethos of Weald Hall is to provide a comfortable and caring environment that promotes independence. Residents are encouraged to manage their own financial and personal affairs. The home has a high standard of decoration and there are spacious grounds. Crossways Trust became the registered owners on 31st May 2005. Activities include poetry readings and newspaper debates, arts and crafts, gardening, exercises to music and trips to churches, shops and pubs. At the time of the visit fees ranged from £535 to £670 per week, inclusive of newspapers and standard toiletries. Additional charges are payable for hairdressing, chiropody, manicures and reflexology. A copy of the latest inspection is kept in the manager’s office. Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first key unannounced visit to the home for the inspection period 2006/07. Lead inspector Elizabeth Baker carried out the visit on the 27 February 2007, which lasted about eight hours. As well as touring the home, the visit consisted of talking with some residents and staff and inspecting some records for case tracking purposes. Four residents, one visitor and two members of staff were interviewed in private. Feedback was provided to the deputy manager at the conclusion of the visit. At the time of compiling this report, in support of the visit, the Commission received comment cards about the service from eight residents. At the Commission’s request the home manager completed and returned a preinspection questionnaire. Three survey forms have subsequently been received from Health Care Professionals and one from a relative/visitor. Some of the information gathered from these sources has been incorporated into the report. At the time of the visit 22 services users requiring personal care were residing at the home. What the service does well: Residents made positive comments about the home and staff during the visit. These included “care and support is 10 out of 10”; “staff could not be better”; “bedroom always kept clean””; “staff listen to what I say”; “I’m glad I chose this home”; “my room is always kept clean and tidy”; “management and staff are terrific”; “staff could not be nicer, everyone gets on well together”; “very good food” and “staff are kind to me”. Prospective residents are able to stay at the home for a trial period before deciding on whether to move in on a permanent basis. Visitors are welcome at any time. For a small charge visitors are invited to have meals with their relative/friends for special celebratory occasions. The home is kept clean and fresh. Residents and a visitor spoken with indicated this is always the case. Staff should be congratulated on this. Surveys from Health Care Professionals included extra comments such as “[the home] “offers a safe, caring environment”, [the home] provides efficient management and is patient centred” and “they care for the clients extremely well. The home has a pleasant atmosphere. There are plenty of activities for the clients to take part in”. Despite the visit being unannounced, the registered manager not being available and two staff not reporting for duty, there was a calm atmosphere Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 6 throughout the home during the inspection. Shifts are arranged so the home manager or deputy manager manages the home over a seven-day period. 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 Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 8 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 Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 9 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, 4, 5 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents move into the home knowing their needs can be met and that their independence will be maximised and promoted. EVIDENCE: The home manager normally visits prospective residents in their current environment, prior to a decision of admission being made. Details of the information gathered at these visits, is recorded on a pre admission assessment. A new pre admission assessment form has been introduced. However although the new form generally follows the principles of daily living activities, the information recorded under each section is limited. Following a recommendation made at the last visit the home now confirms in writing to new residents that the home is able to meet their needs. As part of the home’s admission process, prospective residents are not only invited to visit the home, but trial stays are also encouraged. The home is not registered for intermediate care. Standard 6 is not applicable. Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are potentially at risk because care records do not provide meaningfully information about their needs, support, risks, preferences, expectations and wishes. Personal care is offered in a way to protect residents’ privacy and dignity and promote independence. EVIDENCE: Four care records were inspected. The records include pre-admission assessments; admission and short term care plans, long-term care plans, daily progress charts and a selection of clinical risk assessments. Not all plans evidenced they had been composed with input from the resident and or their advocate. Clinical risk assessments are available to monitor the treatment plans. However some assessments had been left blank and in one case it was difficult to monitor a resident’s weight because weights had been recorded on different forms. The records include a moving chart. For a resident who requires the support of a walking aid, this information had not been included in the moving assessment. The resident’s records indicated the resident had Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 11 endured some falls. The resident’s room has some additional steps. There was no specific risk assessment for this. A resident described the falls they had had recently and in one case this resulted in them having to go to hospital. None of the files contained prevention of falls assessments. The Commission’s Clinical Trigger – Prevention and Management of Falls in Older People” may prove useful in assisting the home develop such assessments and seeking specialist advice. The document can be obtained from the Commission’s website – www.csci.org.uk. One resident is being treated for a pressure sore and has been provided with appropriate equipment. A long-term care plan component had been instigated for this need. However it was difficult to establish from this record, or indeed the resident’s other records, the actual type of pressure relief equipment the resident had been provided with. Daily progress charts are maintained and some of these contained good information. However it has not been the home’s practice to record entries daily. This could be problematic in the event of the home and staff having to produce evidence of care and support delivered on a particular day. The progress notes for one resident resulted in a chocking incident. However this had not triggered an update of the resident’s care plan. A resident described the level of support they receive from staff when they are assisted with their personal hygiene needs. This was contradictory to that contained in the resident’s care records. Medication administration record charts are maintained. No gaps were seen and codes had been used where a medication had not been administered. However some of the charts did not contain the glossary of codes information. Some prescription entries had been handwritten. However they had not been signed by the transcriber or countersigned by a witness. One of the charts included an administer when required medication (PRN). The resident’s corresponding care plan did not provide specific administration details. The Royal Pharmaceutical Society of Great Britain’s publication The Administration and Control of Medicines in Care Homes and Children’s Services (June 2003) provides useful information in this respect. The publication can be obtained from the society’s website www.rpsgb.org.uk. The deputy manager said residents’ medicines are not routinely reviewed by their GP. Most of the residents are aged over 75 and some take more than four medicines a day. The Department of Health’s National Service Framework (NSF) for Older People says residents prescribed four or more medicines on a regular basis should have a medication review at least six-monthly. Residents receive medical support from District Nurses and other health care professionals. GPs visit when there is a specific need. However, one resident added an additional comment to their survey form that they would like to see a [doctor] from time to time for a check up. The home does not have a dedicated drug room. This means the drug trolley is kept in a storeroom. However, the situation is not ideal as there is no guarantee that medicines are stored in accordance with manufacturer’s instructions with regard to temperatures. The efficacy of some medicines Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 12 could be compromised because of fluctuating temperatures and humidity caused by the current situation. Residents were dressed appropriately with attention to detail where this was important to them. Staff were observed knocking before entering bedrooms. Residents said they had been asked how they wished to be called when they were first admitted into the home. Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 13 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The meals in the home are good offering both choice and variety. Residents are kept informed of events and activities, helping them to make informed choices on how to spend their time. EVIDENCE: Arrangements are made for residents to part take in activities, socialise with others and to be as independent as possible. Visitors were seen coming and going throughout the visit. Special lunches are arranged for celebratory purposes and residents are able to invite their guests to these functions. Exercise sessions are held twice a week at the home and residents appreciate these. A number of residents said how much they enjoy the quizzes and others mentioned the poetry readings and current affairs debates they have when articles from some national newspapers are read out. Some residents were seen sitting in their rooms listening to the radio, watching TV or reading. A church service is held at the home monthly and residents are able to take Holy Communion if they wish to. Indeed the majority of survey forms returned from residents indicated there are activities arranged by the home that they can take part in. Residents are provided with a weekly activities programme. Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 14 The copies seen had been printed in large print, making the information easier to read. The activities programme has been changed to allow residents some free time as some felt duty bound to attend afternoon activities. This follows comments received at a recent residents’ meeting. Residents are able to bring small pieces of furniture with them making the bedrooms much more homely. Since the last visit meal preparation is now the responsibility of contract caters. New menus have been devised and are now being trialled and more choices are available. Although the inspector did not have a meal at the home an appetising smell permeated the dining room area. Tables had been nicely laid in preparation of the meal. Residents have the choice to eat in the dining room or in the privacy of their own bedrooms. Residents spoken with indicated they enjoyed their meals and one resident added that they had noticed an improvement already. Mixed responses were received from residents about the time they wait between courses. Some residents are happy to wait for everybody to finish one course before receiving the next, while others are not. The home is trying to reach an amicable solution and the topic is included in residents’ meetings. The Commission’s InFocus publication Highlight of the day? Improving meals for older people in care homes (March 2006) may provide some useful information in this respect. A copy was left with the deputy manager. The majority of returned survey forms from residents indicated they always or usually like the meals at the home. Weald Hall DS0000064881.V323695.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. 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. Residents can be confident their complaints are listened to and acted upon. EVIDENCE: The home has a complaints procedure and a copy of this is incorporated in the Welcome Pack, which has been provided in each bedroom. However it was suggested that a copy of the home’s complaint procedure be publicly displayed in the event of a visitor or member of the public requiring this information. Residents spoken with clearly knew who to speak to if they had a complaint, concern or niggle. The training matrix indicates that the majority of staff have received abuse awareness training and others have also received abuse of vulnerable adults training. The two members of staff described appropriately the action they would take if they suspected abuse had taken place. Weald Hall DS0000064881.V323695.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 25 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 is good providing residents with an attractive, homely and clean place to live. EVIDENCE: On the day of the visit the home was clean, warm and welcoming. Furnishings are domestic and provide for a homely environment. As part of the home’s ongoing improvement programme, some bedrooms have been redecorated and re-carpeted, a number of windows have been replaced, waste plumbing in some en-suite rooms has been renewed and industrial washing machines and dryers have been acquired. The flooring in en-suite rooms is to be replaced with a non-slip type and the kitchen refurbishment is due to start in April 2007. The home sits within a 17-acre site and offers many bedrooms extensive views of the grounds and valley beyond. Indeed some residents said how much they Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 17 enjoy walking in the garden. Other residents spoke of the enjoyment they get from sitting in their rooms and looking at the scenery and landscape from their windows. To improve residents’ safety, radiators in residents’ bedrooms have been covered and restrictors have been fitted to some windows. Heated towel rails in bathrooms have been turned off and arrangements are in hand to have them disconnected. This action is to maximise residents’ safety. Bedrooms vary in shape and size and some have ensuite facilities. One bedroom visited has a raised area, which required the resident having to step up if they wish to access the window area. Handrails had been put either side of the wide platform. However there was no recorded evidence in care records that bedrooms had been assessed and details of the limitations and risks considered. Standard 38 also refers. Handrails are fitted to corridor walls on the first and second floors. However, the provision has not been extended to ground-floor corridors. The home has a four-person passenger lift, which accesses the first and second floors. However three bedrooms have to be accessed by additional steps. Hoists and accessible bathrooms are available for residents requiring assistance. Most toilets and bathrooms had appropriate hand-washing facilities, including hand sinks, paper towels and liquid soap. However there was no designated hand washbasin in one bathroom necessitating staff to use a basin in another room. This arrangement could result in door furniture being contaminated and may lead to cross infections. Weald Hall DS0000064881.V323695.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well staffed. Residents could be potentially at risk because robust checks are not always carried out. EVIDENCE: In addition to care staff, staff are employed for activities, maintenance and laundry duties. The one domestic post is vacant and despite best attempts is proving difficult to fill. Staff rotas are maintained and demonstrate the home is staffed 24 hours a day. Staff were seen carrying out their duties in an unhurried manner, despite unscheduled staff absences. Half of the survey forms returned from residents indicated staff are always available when needed. Sadly one survey form contained the additional comment “on some occasions as was explained to me, no one can be in two places at once – I understand”. The pre inspection questionnaire form indicates 39 of care staff are now trained to NVQ level II care or above. In addition, it records staff have received training on numerous topics including manual handling, healthy eating, infection control, first aid, abuse and medication awareness. Two staff files were inspected. Although there was evidence that application forms are completed, references are sought and provided; employment history details were incomplete and there was no recorded evidence gaps had been Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 19 investigated. New staff are subject to criminal bureau record checks. Copies of the Commission’s InFocus publications Safe and sound? – checking the suitability of new care staff in regulated social care services (June 2006) and Better safe than sorry – Improving the system that safeguards adults living in care homes (November 2006) were provided to the deputy manager. These may assist the home in developing its recruitment practices further. Weald Hall DS0000064881.V323695.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management of the home is satisfactory and the manager has a clear understanding of what needs to improve. However, residents’ records are not well maintained, which could potentially place residents at risk. Residents and advocates expressed satisfaction about the service. Systems for resident consultation are good with evidence that their views are taken into account. EVIDENCE: The manager has been in post for almost two years and is qualified for the position. The manager has achieved the Registered Managers Award and is now undertaking an Open University degree in Health and Social Care. Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 21 The pre inspection questionnaire form includes details of the home’s policies and procedures. However there was evidence these are not all being reviewed annually. This situation may prevent staff working in accordance with current good practice and indeed current legislation. Meetings are facilitated at the home for residents, relatives and staff to meet. Minutes of these meetings are made available to attendees and other interested parties. Although there is no structured quality assurance audit being carried out on an annual basis, the provider intends to introduce such a programme. Copies of the home’s inspection reports are kept in the manager’s office. However the availability is not advertised. The home receives regular visits from the provider’s representative. This enables the representative to meet with residents, visitors and staff to determine views and opinions of the service. The home is not responsible for maintaining personal monies on behalf of residents. However facilities are in place for residents to securely store small items of importance or value. Where this is used, appropriate records are maintained. Not all care staff are receiving regular supervision. One employee interviewed seemed to recall having had supervision about twice in the last twelve months and the other employee could not remember having received supervision at all. The deputy manager indicated she had received supervision/appraisal on one occasion since August 2005. The pre-inspection questionnaire form indicates in the main the home’s equipment is being serviced regularly. However there was no recorded evidence that water-heating checks for compliance with Legionella was being carried out. The Health and Safety Executive publication Health and Safety in Care Homes might provide useful information in assisting the home in doing this. This can be obtained from the Health and Safety Executive website www.hse.gov.uk. Risk assessments to assist residents transferring into baths were seen in a number of care records. However none of the records inspected contained comprehensive detailed assessments with regard to all moving and transferring activities. Neither did the care records contain prevention of falls assessments, even after the resident had had a fall. The deputy manager said details of residents’ falls are collated and analysed. However there was no recorded evidence that any subsequent action is taken to minimise potential falls. As stated previously within the report, bedrooms vary in shapes and sizes and contain various amounts of furniture and personal items, resulting in some rooms becoming cluttered. This situation could present potential trip hazards Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 22 to some residents. At the last visit to the home in January 2006 it was stated that a professional organisation would be carrying out risk assessments of the home and grounds. An occupational therapist visited the home and made some recommendations. The manager reported that the provider intends to adhere to the recommendations as and when the areas of the home are being refurbished. Not all records relating to residents’ wellbeing are completed as required to ensure all staff have the necessary information to provide care and support to residents. Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 23 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 2 3 X 3 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 2 2 Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 24 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(1,2abc d)13(4bc) Requirement Care plans must contain all information as specified in standard 3 and be reviewed on a monthly basis. Timescale 30/03/06 not met. The home must develop a prevention of falls assessment in order that each resident is appropriately risk assessed. Hand washbasins must be available in all areas where residents are supported with hygiene needs, including bathrooms. Full employment histories must be obtained and any gaps investigated. All records relating to residents must be up to date and complete. Bedrooms must be risk assessed and details of the findings recorded in the residents’ respective care records. Timescale for action 31/07/07 2. OP7 13(4) 31/07/07 3. OP26 13(3) 31/10/07 4. 5. 6. OP29 OP37 OP38 19 17 13(4) 31/05/07 31/05/07 31/05/07 Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 25 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 4 5 6 7 8 9 10 Refer to Standard OP7 OP8 OP8 OP9 OP9 OP16 OP22 OP28 OP36 OP38 Good Practice Recommendations Residents should be able to see their GPs on a regular basis. Daily records should be maintained to provide a holistic picture of each resident’s day. Clinical risk assessments should be complete of all details. Precise administration instructions of “administer when required” medicines should be included in residents’ care records. The home should consider re-locating the storage of medicines. A copy of the home’s complaints procedure should be publicly displayed, for ease of access. The provision of handrails should be extended to all corridors used by residents. 50 of care staff should be trained to NVQ level II care or above. Care staff should receive formal supervision as least six times a year. Appropriate checks should be carried out to the home’s water supply in respect of Legionella and the findings record. Weald Hall DS0000064881.V323695.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Maidstone Kent ME16 9NT 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. 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