Inspection on 25/09/06 for Welbeck House

This inspection was carried out on 25th September 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Welbeck House 10/06/09

Welbeck House 09/06/08

Welbeck House 17/12/07

Welbeck House 14/11/05

Welbeck House 20/10/04

Welbeck House 25/05/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Welbeck House 42 Welbeck Avenue Bushbury Wolverhampton West Midlands WV10 9LS Lead Inspector Rebecca Harrison Key Unannounced Inspection 25th September 2006 09:30 Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 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 Welbeck House DS0000030055.V296551.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 Adults 18-65. 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. Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Welbeck House Address 42 Welbeck Avenue Bushbury Wolverhampton West Midlands WV10 9LS 01902 681909 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) Arcare (West Midlands) Limited Mrs Balvir Sahota Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: No conditions apply Date of last inspection 14th November 2005 Brief Description of the Service: Welbeck House is a traditional semi-detached house and is situated in an urban area of Bushbury. The home offers access to local amenities and transport and the premises are in keeping with the local community. The home is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of three adults with a learning disability. The accommodation provided is on two floors comprising: Two single bedrooms and a bathroom on the first floor and one single bedroom with en-suite on the ground floor. Communal space includes a kitchen, lounge and dining room. The home has a small garden to the rear of the property. The home is owned by Arcare (West Midlands) Limited and the registered manager is Ms Balvir Sahota. The homes philosophy is to Maintain a high standard of care, respecting individuality, privacy, residents dignity and independence at all times. First and foremost a happy and secure environment within the home. The current fees charged per person range from £423.00 to £567.00 per week. CSCI reports for this service can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and commenced at 09.30a.m. and lasted five hours. It was carried out by talking with one service user present at the home, the manager, two members of staff on duty, case tracking two service users, observation of some work practices, examination of a number of records and a full tour of the home. 22 key National Minimum Standards for younger adults were assessed during this inspection in addition to Standards 1,5 and 27 and a quality rating provided based on each outcome area for service users. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The purpose of the inspection was to assess ‘Key’ National Minimum Standards and to review the progress made by the home since the last unannounced inspection undertaken on 14th November 2005, when three requirements and five recommendations were made. The service user, staff, registered manager and proprietor were very welcoming and co-operated fully throughout the inspection. Since the last inspection no complaints have been received by the home or referred to the Commission for Social Care Inspection and no referrals have been made under adult protection procedures. What the service does well: What has improved since the last inspection? Staff training has significantly improved and staff reported that they have developed their skills and knowledge base through attending mandatory and service specific training courses. Staff have recently completed distancelearning training in infection control and health and safety. It was reported that out of the five support staff employed, three hold an NVQ award. The manager Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 6 has completed NVQ awards at level 3 and 4 and has undertaken numerous courses relevant to her role, which has benefited the service. 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. Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place that would enable the successful admission of a new person to the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place which are available to service users and their representatives. The last admission to the home took place over eighteen months ago and appropriate needs assessments were in place and found satisfactory during the inspection undertaken on 5th May 2005. Signed terms and conditions of residency were available on both the care files and were last reviewed in March 2006. Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning systems provide staff with the necessary information to ensure the assessed needs of service users is met. Service users are appropriately supported with making choices and enabled to take responsible risks. EVIDENCE: Two service users were case tracked and their care files reviewed by the inspector. Information was detailed and there was evidence that support plans are reviewed at the appropriate timescales. Staff spoken with during the inspection confirmed that they are provided with sufficient information to deliver the appropriate care. Staff and managers expressed concern in relation to one individual whose physical needs have increased over the past few months and consider that despite the person being reassessed they are unable to provide the required level of care that he now requires. It was reported that staff are undertaking manual handling tasks, for which they are not currently trained in. An assessment was undertaken by an Occupational Therapist on Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 10 24.08.06 and the report states that ‘The shower room is unacceptable for his needs and should be adapted for health and safety reasons and that a ramped access to the home needs to be installed’. Discussions held with managers indicate that they would have to fund any alterations made. The person also requires 2:1 staffing with personal care, which the home are currently funding for two hours of a morning. A Joint review was held on 1.11.05 with the day service the individual attends throughout the week and his care plan was last reviewed in July 2006 by the home. Review minutes were also available on the file of the other person case tracked dated 1.11.05. Since the last inspection a number of staff have attended Person Centred Planning (PCP) Awareness training with the local team based at Pond Lane, however PCP’s have yet to be developed with the people accommodated. One staff member reported that a service user had ‘lashed out’ at her a couple of months ago. It was stated that a referral has been made to the local team in addition to a request for training in the management of behaviours, however the home currently has no clear guidelines in place for staff to work to the interim, which must be addressed given staff are lone workers. The manager reported that one person accesses an advocacy service provided through the day service he attends. A report seen on one persons file stated that the individual is assertive and capable of making affective choices. The service user present during the inspection was offered choices in relation to his breakfast and where he would like to go for lunch. It was reported that residents meetings are held on a regular basis and that the families play an active role in the lives of their relatives and represent their interests in addition to service users being provided with designated key workers, who have developed positive working relationships with the people they support. Various risk assessments seen on files evidence that people are enabled to take responsible risks, which are regularly reviewed and updated. Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with educational and social opportunities. They are supported to keep in contact with their families and friends and offered a diet respecting their individual preferences and dietary needs. EVIDENCE: Two of the people residing at Welbeck House access local authority day service provision five days per week and the other person attends two days a week and is supported at home for the remainder of the week. Daily records seen evidence that service users are provided with opportunities to access their local community on a regular basis through their day service and the home. During the inspection one person was supported to have lunch out in the community and appeared to enjoy partaking in this. Family links are well established and people are supported to maintain contact through telephone calls and visits. The person present informed the inspector that his sister had very recently visited the home. Staff also reported that he Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 12 also visits a local home owned by the organisation and has developed a friendship with a person living there. Preferred routines were documented on the files reviewed and on arrival at the home the service user present was just getting up for the day after having a lie in, which he said he enjoys having. It was reported that service users are supported with basic housekeeping tasks as much as possible according to their ability and have unrestricted access to the home. Observations made throughout the inspection and discussions held with the staff present evidence that service users rights are respected and that people choose when to be alone or in the company of others. It was reported that two people have a key to their bedroom door and are able to use this facility. Following a concern previously raised by a relative in relation to the quality of food provided a recommendation was made at the previous inspection that service users be offered a greater variety of branded foods. The manager reported that she has consulted with families and the issue has since been satisfactorily addressed which was evidenced in a letter seen from one relative. An inspection of the food store indicated that the home now purchases some branded food and staff on duty reported that service users choose what food they wish to eat. The service user present confirmed that he is supported with food shopping for the home. A record of all food consumed is maintained by the staff on duty and a menu is available. It was reported that one person has special dietary requirements due to health reasons. Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health needs of service users are met with evidence of good multi disciplinary working taking place on a regular basis. The home has a satisfactory system for receiving and storing medication however procedures for recording administered medication require review to fully safeguard service users. EVIDENCE: Personal support requirements and preferred routines were documented on the two care plans reviewed. The service user at home during the inspection was well presented. It was reported that two service users have received full medical health checks and are awaiting Heath Action Plans to be developed. The other person has recently changed general practitioner and the manager reported that she has requested a health check to be undertaken. Health records seen on the file of the two people case tracked evidence that service users are supported to access NHS Health care facilities and their health is closely monitored. Forthcoming health appointments were also seen in the homes diary. As previously stated one person has recently been assessed by Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 14 an Occupational Therapist and the report indicates that some elements of the environment are currently challenging his physical needs. Two recommendations were made at the previous inspection that incoming prescribed drugs be checked, recorded and signed off and that individual service user MAR charts be sectioned with a photograph of the service user. The findings of this inspection evidenced that both recommendations have since been met. Medication procedures appeared satisfactory at the time of the inspection with the exception of recording of medication administered. A review of MAR charts evidenced four gaps for one service user and one gap for another. The staff member on duty at the specified times confirmed that she had administered the medication and fully acknowledged that she had failed to record this as required. The home uses the monitored dosage (MDS) system provided by Boots Chemist and staff have received training in this system. The manager reported that two staff have undertaken accredited distance learning training on the administration and safe handling of medicines. The manager stated that a pharmacist employed by Boots Chemist is due to visit the home shortly to review the homes medication procedures. None of the service users are currently prescribed controlled drugs. The manager is aiming to provide information on the medication that service users are currently prescribed and their side effects in order to provide staff with a greater understanding. Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their representatives are able to express their concerns, and have access to a complaints procedure. Procedures to safeguard service users from potential abuse are in place and the staff team are provided with the necessary training in the local policy and procedure. EVIDENCE: No complaints have been received by the home or referred to the Commission for Social Care Inspection (CSCI) since the last inspection. The complaint procedure is available and the manager has recorded that service users have been made aware of the procedure. The manager has been trained as a trainer for adult protection through Wolverhampton City Council. A member of staff on duty confirmed that she has received training in adult protection. A letter seen on the file of the other staff member evidenced that training has been applied for and in the interim the manager has provided staff with a basic awareness of the local procedure. The manager confirmed that no service user is subject to physical intervention and that she has attended training in the Management of Actual and Potential Aggression (MAPA). The remainder of the team are awaiting dates to attend this training provided by Social Services however the courses are currently over subscribed. Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 16 Service users are supported to manage their finances, which are held at the Civic office for two people. It was reported that the family of one service user currently hold the finances on his behalf. The finances of the people case tracked were checked and one was an accurate reflection of the records held and the other was found ten pence over. Discussions held with staff and managers in relation to one individual evidence that the current management systems do not offer adequate protection to safeguard the individuals or the staff team and therefore should be reviewed. Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with a clean, comfortable and homely place to live. EVIDENCE: A recommendation was made at the previous inspection that the refurbishment of the bathroom be included in the homes planned maintenance and renewal programme. A review of the documentation and a tour of the home evidenced that the recommendation has not been met. Although the bathroom suite was found clean it is odd in colour and one service user now has difficulty with accessing the bath. It was reported that a new wardrobe and mattress has been purchased for one service user. Bedrooms were found personalised. The home was found clean and tidy during this unannounced inspection. The service user present during the inspection confirmed he helps with jobs around the home. The staff on duty confirmed that they have recently undertaken distance-learning training in relation to infection control and are awaiting certificates. The manager reported that a new cleaning schedule is to be developed shortly and staff will sign when they have completed tasks. Products hazardous to health are stored in the kitchen and although the unit Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 18 has a lock facility, staff were unable to locate the key therefore the products were not being securely stored, which was acknowledged by managers. A recommendation was made at the previous inspection that an index be developed for the COSHH data sheets for easier reference, which has since been undertaken. Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a committed, well-trained and enthusiastic staff team and are safeguarded by the homes recruitment procedures. EVIDENCE: Staff were observed to be accessible, good communicators and interacted appropriately with the service user present at the home during the inspection. Staff on duty had a good understanding of the needs of the individuals whom they support. One member of staff reported that she has attended numerous training courses and has gained her NVQ level 2 award. It was reported that out of the five support staff employed, three staff have obtained an NVQ award. Both staff considered that service users are supported by an effective staff team. No new staff have been appointed since the last inspection and it was reported that the home has no staff vacancies. Recruitment procedures were reviewed and found satisfactory at the last inspection. The manager holds responsibility for staff training and discussions held with her indicate that she takes the role and responsibility seriously and is keen to ensure her staff are provided with mandatory and service specific training. Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 20 Two witness testimonies provided by a local college and a health care professional state that the manager ‘Clearly identifies the learning needs of her staff’ and that she has ‘Expressed commitment to staff development by the provision of regular training’. Since the last inspection staff training opportunities have significantly improved and it is evident that the providers and the manager are committed to providing a qualified workforce. A requirement was made at the previous inspection that a staff training and development plan be developed. The manager has developed individual staff training records, which are well presented however she has not yet had the opportunity to develop an overall team development plan based on staff training needs as identified through supervision and appraisals. Training records and certificates were available on personnel files in addition to evidence of staff supervision. Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38 and 39 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is effectively managed by a competent manager creating an open and positive atmosphere from which the service users benefit. Aspects of performance are being developed. Current working practices do not fully promote the safety of service users and staff. EVIDENCE: Ms Balvir Sahota is the registered manager of the home. She has obtained NVQ awards at levels 2,3 and 4 and since the last inspection has undertaken a number of training courses appropriate to her role to include health and safety, infection control, lone working and risk assessment in mental health. Ms Sahota reported that she is considering undertaking further qualifications in either learning disability or counselling. It is evident through discussions held that that she is very service user focussed and committed to her work. Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 22 Requirements have been made at previous inspections that a report be produced on the findings of unannounced monthly visits required under Regulation 26. Although it was reported that Dr Sharma regularly visits the home, a report of the findings continues not to be produced. Discussions held with the manager evidence that the home has yet to develop an annual development plan as required by the previous inspection. The home has a quality assurance file and although the manager was able to produce sound witness testimonies from numerous professionals as evidence for her NVQ level 4 award, the views of service users, staff and relatives have yet to be sought on how the home is achieving goals for service users. Health and safety procedures were reviewed. A risk assessment to support staff lone working was not available. The physical needs of one individual have significantly increased and as a result he now requires additional staff to support him with maintaining his personal care needs. A moving and handling assessment was not available and the staff have yet to undertake training in moving and handling therefore potentially placing the individual and staff at risk. Only the manager has received moving and handling training however the certificate is now out of date. Accident records, risk assessments, temperature monitoring charts, weekly fire checks, fire plan, staff training and service certificates were reviewed. The last entry for testing of water temperatures was dated 8.5.06 and a certificate for hard wiring was not available however managers reported that the hard wiring had been tested and committed to forwarding a copy of the certificate to CSCI. Both staff on duty confirmed that they have recently undertaken health and safety training and infection control and are awaiting certificates. The health and safety policy must be further developed to include all relevant legislation for safe working practices. Risk assessments for safe working practices to include soiled clothing being carried through the kitchen have been developed as required, however a risk assessment to support staff lone working was not available. It was reported that neither the Fire Officer nor Environmental Health Officer have visited the home since the last inspection and that there are no outstanding requirements. Welbeck House DS0000030055.V296551.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 Adults 18-65 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 3 2 3 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 2 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 x 2 x x 2 x Welbeck House DS0000030055.V296551.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 YA6 Regulation 15(1)(2) Requirement A management behaviour plan must be developed for the person whose behaviours may challenge. Staff responsible for administering medication must sign the MAR chart when they have administered any medication. Appropriate facilities must be provided for service users to bathe/shower based on their assessed need. A staff training and development plan must be developed. (Previous timescale of 28/02/06 not fully met). Timescale for action 16/10/06 2 YA20 13 (2) 26/09/06 3 YA27 23 (2)(j) 16/10/06 4 YA35 18(1)(c) 01/11/06 Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 25 5 YA39 26 (4)(5) A report must be produced on the findings of unannounced monthly visits and be forwarded to CSCI and a copy retained at the home. (Previous timescale of 31/12/06 not met). 01/10/06 6 YA39 24(1)(a&b)(2)(3) An annual development plan based on the homes quality assurance systems must be developed. (Previous timescale of 31/03/06 not met). 01/11/06 7 YA42 12(1) The health and safety policy 01/11/06 must be developed further to include all relevant legislation for safe working practices (Previous timescale of 30/04/06 not fully met). 8 YA42 13 (5) Safe systems for moving and handling a service user must be established and adhered to, staff provided with relevant training and the necessary equipment must be obtained. A risk assessment to support staff lone working must be developed and implemented. 01/11/06 9 YA42 13(4) 02/10/06 Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 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 Refer to Standard YA6 Good Practice Recommendations It is recommended that person centred plans be devised with service users/representatives as soon as possible in addition to health action plans. It is strongly recommended that an independent advocate be sourced for the individual who wishes to remain at the home. It is recommended that support plans be further developed in relation to the level of assistance an individual requires in undertaking personal care tasks. It is recommended that procedures for handling service users finances be reviewed. 2 YA7 3 YA18 4 YA23 Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Welbeck House DS0000030055.V296551.R01.S.doc Version 5.2 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. 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