Inspection on 01/12/06 for Wear Court

This inspection was carried out on 1st December 2006.

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

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

Other inspections for this house

Wear Court 27/05/10

Wear Court 17/05/10

Wear Court 16/03/10

Wear Court 18/02/10

Wear Court 11/12/09

Wear Court 30/07/09

Wear Court 01/08/08

Wear Court 08/11/07

Wear Court 25/01/06

Wear Court 13/09/05

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Wear Court Rock Lodge Road Roker Sunderland SR6 9NX Lead Inspector Irene Bowater Key Unannounced Inspection 09:00 1st December 2006 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 Wear Court DS0000064820.V318728.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. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wear Court Address Rock Lodge Road Roker Sunderland SR6 9NX 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) 0191 5496441 0191 5485305 Moorlands Care Homes (N.E.) Limited Miss Pearl Ann Pope Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2006 Brief Description of the Service: Wear Court Nursing Home provides nursing and personal care for 30 older people. The home is situated in a residential area of Sunderland approximately 50 metres from the sea front and within easy reach of public transport facilities. The three-storey house was originally a residential dwelling and was converted to a care home in 1993. There is a passenger lift, which provides access to most areas of the home. A stair lift provides access to several bedrooms on the first floor that are inaccessible via the passenger lift. There are twenty-seven bedrooms, four of which are double and are currently used as single rooms. Eight single and two double rooms have en-suite toilet facilities however, some are not of a suitable size to allow access for wheelchair users or people with mobility difficulties. Corridors and door widths are wide enough to allow access for wheelchair users. The laundry, kitchen, dining room and lounge areas are all on the ground floor with the majority of bedrooms on the upper floors. There is a conservatory to the rear of the building, which overlooks the private and mature gardens. The statement of purpose and service user guide are not up to date or readily available in the home. Fee rates vary. Low band nursing £399 per week, Medium band nursing £442 per week, high band nursing £492 per week. There are extra charges for hairdressing, chiropody, optician and dental care. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over seven hours. The inspector spent time with the Manager, staff, residents and visitors. The inspector looked around and talked to residents and staff, and saw the contact between them. Time was also spent checking the cleanliness, maintenance and decoration of the home. A number of documents were looked at including, training, maintenance, catering, medication, financial, recruitment, health and safety, and complaint records. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. What the service does well: The staff collect information about the person before anyone moves into the home to make sure they can meet their needs. Staff often talk with other professionals to ensure residents health care needs are met. The staff team have good relationships with the residents and know how to care for them. Comments from relatives and residents include: “They are attentive at all times”, “they are kind and helpful”, “the care and support is very good”, and “ I am more than satisfied with the care given to my relative”. The meals are nutritious, nicely presented and choices are available. Residents agreed with this by saying, “the meals are fine”, “there’s plenty to eat” and “I get whatever I want”. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 6 Visitors are made welcome and there are good links with the local community. Residents said they would be able to use the complaints procedure if they had a concern. The staff receives the training they need to care for the residents needs. The recruitment policies are followed. What has improved since the last inspection? What they could do better: The registered persons need to produce information about the home in a style suitable for potential and current residents and make it readily available to them. The contracts must be clear and set out the rights and obligations of both parties. The contracts need to be changed and signed when there are any changes including changes to fee rates. Further work is needed on the care plans so that they are clear and detailed about the care provided. Improvements are needed to the medicine charts. All areas of the home that need repair, redecoration and refurbishment must be dealt with according to priority need and within agreed timescales. The only negative comments from relatives and residents are about the “poor decoration” and “it needs some work”. All health and safety issues must be dealt with, records kept and completed within agreed timescales. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 7 The registered persons must ensure all requirements in the report are actioned within specified timescales. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wear Court DS0000064820.V318728.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 Wear Court DS0000064820.V318728.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): 1,2,3. Standard 6 is not applicable. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to the service. Residents and their representatives do not receive sufficient information on which to make an informed decision about moving into the home. Residents are unclear about their rights, obligations, fee rates and how changes will affect them. The preadmission assessments make sure that the residents care needs will be met. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home has a Statement of Purpose and Service User Guide, which has had some amendments, made to reflect changes in ownership. However, they still need to be reviewed and updated to show the change in registered manager and other changes that have taken place. The Service User Guide is not in large print nor is it clear and easy to understand. Individual copies are not available to potential and current residents. The responses from the surveys sent out to residents showed that they had received a contract and some information about the home. Residents were unclear about how they were told about any changes to the contract or the fee rates. Four care plans were inspected and showed that the manager carries out comprehensive assessments before any resident is admitted to the home. The care managers and the nurse’s assessments were also available. These records form the basis of the care planning process for the resident. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 11 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): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The care planning system needs further improvement to provide staff, residents and their representatives with the information they need to meet resident’s needs. The health needs of all residents are being met. The systems for the administration of medicines need improvement to ensure resident’s wellbeing. Personal support is currently promoting residents rights to privacy and dignity. EVIDENCE: Each resident has a care plan which is based on the preadmission assessments which are carried out by care managers, home manager and when necessary the nurse assessor. The assessment tools include pressure sore risk assessments, dependency, moving and handling, nutritional assessments using Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 12 the Malnutrition Universal Screening Tool (MUST), continence and fall risk assessments. The four care plans examined showed that they were not fully completed, dated and signed. This means accurate information that residents care needs are met is not available. Risk assessments and evaluations of care were not carried out at least monthly. There is limited information about resident’s previous lifestyles and social care needs. None of the care plans were signed by the resident or their representative. Staff have a good knowledge of individual residents needs. They were able to describe how individual needs and risks would be managed. All of the residents and relatives spoken to were satisfied with how the staff managed their care. Comments included: “The care and support is good”, “they are always attentive and make sure my relatives health care is good”. The residents have access to all NHS facilities. There are regular visits from GP’s and other health professionals including dentists, opticians and chiropody services. Advice is sought from tissue viability specialists, speech therapists and continence advisors. Visits from the multi disciplinary team are recorded in individual care plans. The home has medication policies and procedures for staff to use. Records are in place for all medicines received, administered and disposed of. An audit of Controlled Drugs and the Medicine Administration Records (M.A.R.) showed no discrepancies. However, handwritten directions on the M.A.R. sheets did not have two witness signatures. The treatment room is very small and warm. The room temperature is not recorded to make sure 25C is not exceeded. There is a register of staff who are authorised to administer medication and a nominated member of staff now has responsibility for medication. This has improved the systems since the last inspection. Residents spoken to felt that they are treated with respect and their right to privacy is upheld. Residents spoke about their personal wishes and preferences, which are respected by staff. Examples include locking their bedroom doors, receiving their mail unopened and being addressed by their preferred name. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 13 There was a good rapport between staff and residents, which was friendly and professional. Care was delivered in private and staff were seen to knock on doors and wait for permission before entering. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Social activities provide stimulation and interest for residents living in the home. Support from relatives and representatives provide residents with opportunities to maintain their previous lifestyles. Residents are supported to make choices and take control over their lives. Dietary needs of residents are catered for with a balance of food available that meets residents’ needs. EVIDENCE: The home has now employed an activities organiser. Activities are displayed and include chair exercises, music, quiz sessions, arts and crafts and cooking. Records and photographs of activities are available. A number of residents said they were happy to provide their own entertainment and said the staff would take them for a walk along the sea front or go shopping if they wanted to. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 15 On the day of inspection the staff were busy decorating the home for Christmas. The residents have made Christmas cards, which are displayed in the entrance. The residents confirmed that family and friends are welcomed and can visit at any time. The staff took time to talk to visitors and share information with the residents consent. Residents have been encouraged to bring small items of furniture and other belongings with them, making their rooms highly individualised and reflective of their lifestyles. They are encouraged to take responsibility for their own financial affairs for as long as possible. Information about advocacy is available in the home. The home has one large dining room, which has recently been redecorated. This has improved the room, however there are not sufficient dining room chairs which are suitable for the residents to use. The dining tables are set in rows, which makes conversation difficult. The provision of large round tables would enable residents to better interact with each other during mealtimes, and ‘glider’ type chairs would be more comfortable and safer for residents to use. The dining tables were appropriately set with tablecloths, cutlery, crockery and individual condiments. Lunch was taken with some of the residents. There was a choice of fish with parsley sauce or homemade corned beef pie with potatoes or chips and peas. Dessert was jam sponge and custard and alternatives of ice cream, yoghurts, and fresh fruit were also available and offered. Cold drinks were readily available throughout the meal. The meal was of ample portion size, nicely cooked and presented. The staff were kind and attentive to all of the residents and the lunchtime meal was a pleasant period. The cook prepared a tray of various cheeses and fruits to be served with hot and cold drinks and biscuits during the day. All of the residents said the “food is good”, “we get nice food”, “I choose what I want and the staff make sure I get it”. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 16 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): 16,18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The complaints procedures are clear. Residents and relatives are confident that their views are listened to and acted upon. Arrangements for the Protection of Vulnerable Adults are satisfactory and protect residents from harm. EVIDENCE: There is a complaints policy and procedure in place. The procedure is available in residents’ bedrooms. The residents said they would be able to use the procedure if necessary. They said, “the staff sort things out if they had a problem.” Five complaints have been received since the last inspection. These are documented in the complaints register with outcomes recorded. There is a Protection of Vulnerable Adults (POVA) procedure in the Home and a Whistle blowing policy. The Local Authority Multi Agency Procedure for the Protection of Vulnerable Adults (MAPPVA) is also available in the Home for staff guidance. Staff have received training on the protection of vulnerable adults. Staff were able to describe and give an account of appropriate actions to be taken on suspicion of, or witnessing abuse. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,25,26. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to the service. The Home is generally clean and warm however, the poor quality of the decoration and furnishings places residents and visitors at risk. The home does not provide a safe, pleasing environment in which to live. There are infection control and safety issues, which potentially place residents at risk of harm. EVIDENCE: Limited progress has been made with the major refurbishment needed in the home. Previous requirements about the areas which need to be improved have not yet been met. A walk around the building showed a threadbare carpet in one lounge, the lounge chairs are worn and the conservatory is sparsely furnished. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 18 When the stair lift was repaired the wallpaper was damaged and has still not been redecorated. There is damage to all of the paintwork through wear and tear and use of wheelchairs and trolley’s. There are bathrooms and toilets close to all resident areas. The Parker bath on the ground floor is broken which means the residents have to go upstairs when they want bathing. Currently there are not sufficient adapted bathrooms to meet residents’ needs. Two of the baths are domestic in style and residents are unable to use them safely. Unused bathrooms are cluttered with old and damaged items. The paintwork and flooring in all of these areas is damaged and not easily cleaned which is a control of infection risk. The home is making limited progress with the redecoration of bedrooms. Many still are in need of refurbishment. There is damage to walls and the furniture is shabby and worn. The armchairs are stained; carpets are worn and not easy to clean. One resident said his wardrobe door had been “broken for ages”. The resident’s belongings make their rooms comfortable and reflective of their lifestyles. The lighting in the several areas of the home is dim. There is evidence that the lighting in the dining room is being replaced. Lighting in the rest of the home needs to be checked to make sure it is domestic in style and bright enough for reading and other activities. The water temperatures are variable. The water temperatures currently are not recorded each week, dated and signed. Staff say they check the bath water temperature, however not all bathrooms have a bath thermometer. Thermostatic mixing valves need to be fitted to prevent risks of scalding. Water in unused bathrooms is not run on a regular basis. Despite all of the issues identified the home was clean, tidy with no odours in the communal and bedroom areas. Pull cords in bathrooms and toilets were grubby and knotted or too short to be accessible in the event of a resident falling to the floor and doors to a linen cupboard and sluices room were left open. The use of bar soap was evident in several areas and liquid soap and paper towels were not available in all resident areas to allow effective hand washing. The sluices had an odour problem, bins were overflowing and had no lids. The laundry is separate from resident areas. New machines have been provided, however they are for domestic use and do not have a sluice facility. Soiled items have to be carried through the home to the nearest sluice. The walls and floors are damaged and cannot be cleaned effectively. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The current staffing levels and staff deployment ensures the residents assessed needs are met. The arrangements for training and recruitment ensure that residents are protected and staff are competent. EVIDENCE: The home now has a registered manager in post .The core staff have been in post for some time and have formed a stable team. On the day of inspection the staffing levels were sufficient to meet the residents needs. This included qualified nurses, senior care and care staff. There were sufficient ancillary staff on duty including laundry, catering, and an activities organiser. The maintenance person works 16 hours per week. Over 98 of care staff have completed NVQ training to level 2. Five staff files were inspected. The records for recruitment were satisfactory. There was evidence of Criminal Record Bureau checks, Protection of Vulnerable Adult checks, two written references, proof of identity and professional identity numbers for registered nurses. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 20 Staff confirmed that they get plenty of training and were supported by the manager. The records confirm that the following training has taken place:dementia awareness, skin hand care, tissue viability documentation, use of a syringe driver, moving and handling, food hygiene, safeguarding adults, and palliative care including use of Liverpool Care Pathways. The home is accredited with Sunderland University to take student nurses on placement. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 21 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): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The manager is appropriately qualified to manage the home. The systems for consultation and quality monitoring are in place with evidence that views of residents and their representatives are being sought. Residents personal accounts are managed to ensure their best interests are protected. Some facilities in the Home, and health and safety practices carried out do not fully promote and safeguard the health, safety and welfare of the people living there. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager has been in post for one year. During this time she has completed the process with the Commission to become the registered manager and has completed the Registered Managers Award. She is a first level registered nurse and has many years nursing experience. Since coming into post various audits have been completed. These include kitchen, laundry and the environment. Questionnaires have been sent out and the results are being collated. The general outcomes are that everyone is always made welcome, staff are approachable and satisfied with the care. Comments from the surveys also bear out the findings from the report in relation to the environment for example, needs decorating, the bedrooms are poor. The reports from the provider under Regulation 26 are not available on a monthly basis. Resident’s personal financial records were inspected. A record is maintained for each person’s transactions. Entries were clear with signatures available. A random check of balances and cash were found to be correct. The training records show that the staff have received training in safe working practices. The fire records show that the names of staff are recorded but they do not sign to confirm they have attended any training. The fire risk assessment needs to be reviewed and updated following the new guidance. Records for risk assessments for example checking window restrictors is not detailed, and dated. Accidents are clearly recorded and the manager completes monthly accident analysis to examine and track any trends. Contract maintenance certificates are available and generally up to date. The recommendations from findings need to be implemented. The five-year electrical test certificate is dated 2000 and needs to be renewed as a matter of urgency. There are some practices for example leaving sluice doors open and equipment shortfalls, which pose hazards to residents. Other health and safety hazards and risks have been identified in other parts of the report and were discussed with the manager. Wear Court DS0000064820.V318728.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 1 1 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 1 1 1 2 X 2 2 2 STAFFING Standard No Score 27 3 28 3 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 1 Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? 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 registered persons must ensure that the statement of purpose is reviewed and up dated. It must clearly set out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home. The service user guide must be provided to current and prospective residents and be in a format that is suitable for them. Timescale of 28/02/06 not met. The registered persons must ensure that all residents are provided with an up to date contract. When there are any changes a further contract must be issued setting out the terms and conditions including changes to the fee rates. The registered persons must ensure that the care plans set out in detail the action to be taken by staff to ensure that all aspects of the health, personal and social care needs of residents is met. The care plans must be reviewed at least monthly, updated to DS0000064820.V318728.R01.S.doc Timescale for action 01/04/07 2 OP2 5 01/04/07 3 OP7 12,13,15 01/02/07 Wear Court Version 5.2 Page 25 4. OP9 13 (2) 5. OP19 23(2)(b) 6 OP20 23 7 OP21 23 8 OP21 16,23 9 OP24 16,23 10 OP25 23 reflect changing needs and current objectives for health and personal care. The care plans must be drawn up with the residents and signed by them whenever possible. The registered persons must ensure that all handwritten directions on the Medicine Administration Records (M.A.R.) have two signatures. The treatment room temperature must be recorded to ensure 25C is not exceeded. All matters concerned with the safe environment, décor and furnishings must be addressed within a planned programme. Timescale of 31/03/06 not met. The registered persons must replace to lounge carpet and provide furnishings that are domestic in style and of good quality. Lighting in communal rooms must be domestic in style sufficiently bright and positioned to facilitate reading and other activities. The registered persons must ensure that there is a ratio of 1:8 assisted bathing facilities provided for residents. The Parker bath must be repaired or replaced. The registered person must ensure that all bathrooms and toilets are redecorated within a planned refurbishment programme. The registered persons must continue with the redecoration and refurbishment of the bedrooms. The registered persons must ensure that all lighting in residents’ accommodation meets recognised standards (150 lux). DS0000064820.V318728.R01.S.doc 01/01/07 01/06/07 01/05/07 01/02/07 01/06/07 01/06/07 01/06/07 Wear Court Version 5.2 Page 26 11 OP26 12,13,16, 23 12 OP38 13 (4) 13 OP38 12,13,23 To prevent risk of scalding preset valves of a type unaffected by changes in water pressure and have fail safe devices must be fitted to provide water close to 43 C. The water must be flushed regularly in all unused bathrooms and toilets. 01/06/07 The registered persons must ensure that liquid soap and paper towels are available in all resident areas to enable effective hand washing. All call cords and light cords must be in easy reach, free from knots and easy cleanable. Suitable bins with lids must be provided to assist with odour and infection control. The walls and floor in the laundry must be impermeable and easily cleanable. The washing machines must have the specified programming ability to meet disinfection standards. The practice of transporting soiled items from the laundry to the sluice must be reviewed. The registered persons must 01/01/07 ensure that all areas of potential hazard to residents are kept locked. Timescale of 25/01/06 not met. The registered persons must 01/04/07 ensure that the fire risk assessment is reviewed and updated. All staff must sign to confirm they have completed fire training. The risk assessments for window restrictors must be completed in detail. The five-year electrical test must be completed. The registered persons must DS0000064820.V318728.R01.S.doc Version 5.2 Page 27 Wear Court ensure that the health and safety of residents, staff and visitors is maintained at all times. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP33 Good Practice Recommendations The development of quality assurance systems should be pursued in order to monitor all services provided by the Home. Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South of Tyne Area Office St Nicholas Building St Nicholas Street Newcastle NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wear Court DS0000064820.V318728.R01.S.doc Version 5.2 Page 29 - 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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