Inspection on 30/06/05 for Welby Community Unit

This inspection was carried out on 30th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Welby Community Unit 06/03/07

Welby Community Unit 18/01/06

Welby Community Unit 10/01/05

Welby Community Unit 25/08/04

Welby Community Unit 28/02/04

Welby Community Unit 04/12/03

Welby Community Unit 18/03/03

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

CARE HOME ADULTS 18-65 Welby Community Unit 203 Outland Road Peverell Plymouth PL2 3PF Lead Inspector Kim Fowler Announced 30 June 2005 th 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 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 Stationary 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. Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Welby Community Unit Address 203 Outland Road, Peverell, Plymouth, Devon, PL2 3PF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01752 794544 01752 768226 Plymouth City Council Heather Ann Rogers Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age 18-65 years 2. Service Users with learning disabilities who may also have physical disabilities Date of last inspection 10/01/05 Brief Description of the Service: Welby Community Unit is a care home providing personal care and accommodation for 12 persons with a learning disability, aged 18 – 65, who may also have a physical disability.It is owned by Plymouth City Council and provides a respite service for approximately 50 – 60 service users.The home is located in the residential area of Peverell, close to shops, pubs and other amenities.The home was opened in 1987 and consists of a detached two-storey property. The home only has level access and facilities for service users with profound mobility difficulties on the ground floor. The home has seven single bedrooms and two shared rooms on the 1st floor, none of which have en-suite facilities. There are bathing and toilet facilities close to bedrooms and communal areas. There are lounge and dining rooms, as well as a room that is used as a sitting room and activities area. There are facilities in the latter room for service users to prepare their own drinks and snacks. There is a call alarm system in some of the bathrooms, toilets and hallways. The garden is spacious and accessible to the service users. Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 7 hours and was a planned Announced inspection. A full tour of the premises took place and staff and care records were inspected. Some of the staff and 4 of the service users were spoken with during this inspection as well as the Registered Manager and the . The CSCI received 1 Relatives/Visitors comment cards. What the service does well: What has improved since the last inspection? What they could do better: The home should use the quality assurance questionnaire for the visiting professional and audit the results with the other completed questionnaires. Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 6 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. Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 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 standard(s) 1/2/3/4/5 Service users in the home can be confident that Welby Unit provides information on the Statement of Purpose and Service Users Guide enabling them to make an informed choice of care home. EVIDENCE: The home had a statement of purpose and service user guide and evidence was seen of these documents having been updated recently. The service user guide is also available in a format using photographs, symbols and pictures, and is on audiotape. Discussion with the Registered Manager and information contained in service users’ files showed that all referrals for admission come from Social Services. The home has a referral and eligibility criteria for any new service users and evidence was seen of referrals forms completed. Any new service users have an assessment carried out by Care Managers and the staff of the home is involvement. Case tracking also provided evidence that risk assessments and any behavioural management are clearly documented. The home had a documented procedure for admissions, including emergencies and any emergency admission have a monthly strategy meeting arranged by the home with care management involvement. A discussions with the Registered Manager and staff and information contained in service user’s plans, showed that needs were being met and specialised services involved when required. Staff was trained in different methods of communication and it was evident that the importance of non-verbal communication was understood. Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 9 One new service user was due to visit the home on the day of the inspection. Emergency admissions don’t always have trial visits. The manager informed the inspector that one service user has recently had 10 visits and is due to stay over night later this year. Case tracking provided evidence in one service user file showed that the home has local authority contracts and terms and conditions were available. Some of the contracts had not been signed due to service users needs. Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 10 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 standard(s) 6/7/8/9/10 Due to the mixed needs of the service users in the home some are unable to make many decisions but are encouraged to as much as possible. EVIDENCE: The service user care plans seen during this inspection provided evidence that all areas of health and welfare, were reviewed regularly, and produced in a format combining symbols and writing. Files contained comprehensive risk assessments, as well as guidelines for managing individual behaviours, and manual handling assessments where necessary. The Registered Manager confirmed that these were drawn up with the involvement of the service user and, where possible, care plans were signed by service users. Each service user had a key worker and the roles/responsibilities were documented. A discussion with the Manager, staff, and information contained in service users’ care plans indicated that service users were enabled as much as possible to make decisions about their lives. Records inspected showed that any limitations on choice or freedom were documented and a discussion with the Manager confirmed that service users and representatives were involved in these decisions. The home has an Independent advocacy service available and the information was displayed on a notice board. Since the last full inspection the home has change the way the service user money is managed. Each Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 11 bedroom now has a safe fitted, money is checked in by the staff, and service users were possible, and money is kept individually in each safe. Checks and records seen during this inspection confirmed that money was correct and well documented. Discussions with some of the service users, manager and staff, highlighted that service users were consulted as much as possible, and participated, in all aspects of life in the home. The amount of involvement varied depending on individual service users abilities. Service users are encouraged to attend staff meetings if they wished. The home holds regular service users’ meetings and these meeting are documented. Were possible the Manager consults the service users about the home and are provided with verbal information about the policies, procedures, activities and services. Case tracking provided evidence that contained in individual service users’ files were risk assessments. These indicated that service users were enabled to take responsible risks that had been assessed and risk and behavioural management strategies were in place. The home had a comprehensive missing person’s procedure in place as well as a procedure relating to unexplained absences. The home had a comprehensive confidentiality policy, which was a Plymouth City Council corporate policy and all staff were required to sign the confidentiality policy. Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 12 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 standard(s) 11/12/13/14/15/16/17 The service users in this respite home can be confident that they will participate in the local community and will be supported by staff when needed. EVIDENCE: Service users are encouraged to maintain and develop independent living skills as much as possible within the respite setting. Personal development opportunities were actively encouraged and documented in service users’ files. The home had an activities/resource room that contained various items of kitchen equipment where service users could prepare their own snacks and drinks, and develop cooking skills, with supervision from staff. Discussions with the Manager, the assistant managers and case tracking service user files showed that service users participated in many activities outside the home including attendance at day centres, colleges and work placements. The home was not responsible for organising educational or employment opportunities as the home only caters for respite care. The home does not have its own transport but is able to use a people carrier from the local day service. The service users in the home participate in various leisure activities both inside and outside the home including independent living skills and many other Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 13 housekeeping tasks that service users wished to participate in. Activities outside the home included bowling, theatre and cinema. The home had a resource pack for service users seen in the resource room that was available to assist service user choose activities. The home now arranges parent/carers/staff meetings. The next care meeting is due to take place next week and the manager is trying to arrange a guest speaker to attend. Privacy is respected and staff are to knock on bedroom doors before they entered. All the bedroom doors have fitted appropriate locks that were accessible from the outside in an emergency. Service users have keys based on individual risk assessment. The service users have unrestricted access to the house and garden. Any personal mail is given individuals with staff assistance were needed. Individual service users’ files recorded their preferred form of address. Meal times are flexible and service users could eat their meals where they chose, apart from the lounge room. Special diets are catered for and the home has a three weekly menu for the main meal in the evening. Alternatives are available on request. The home had a menu board with symbols denoting the meal for each day. Service users could choose what they would like for their meals and choice was facilitated by the use of symbols, pictures and photographs. Snacks were available throughout the day and evening. Records were kept of the main meals provided and alternatives also recorded. Individual care plans indicate if assistance is needed with eating. Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 14 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 standard(s) 18/19/20/21 This home provides excellent personal support for the service users during their respite stay. EVIDENCE: A discussion with the Manager and some staff indicated that service users were provided with personal support in private, with due regard for dignity and independence. All bedrooms are single to aid privacy. Details of personal care needs and preferences were recorded in service users’ plans and service users had a choice, were possible, of which staff worked with them. Any specialist advice, guidance and support can be obtained via O.T and community nurse if required. All health care visits are recorded into individual care plans. All accidents and incident are recorded and the manager keeps a chart recording this number. All visits of health care professionals took place in private. Due to the respite nature of the home, service users retained their own doctor. Any outpatient appointments are support by the staff if needed. As the home only provides respite care the procedure for medication is that it is checked in and out of the home for each service user on every visit and the homes policies and procedures were seen for staff to follow. The local pharmacist visits and checks the medication every 6 months. The staff received medication training from the home’s pharmacist and a Community Nurse and specialist training on the management of diabetes is also arranged. The home only caters for respite care and the ageing and death of a service user does not usual affect this Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 15 home, however the wishes of service users and/or relatives had been documented. Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 16 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 standard(s) 22/23 The home has a clear complaints procedure, also available in sign, in place and service users can be confident that their complaints or concerns will be listened to and dealt with. EVIDENCE: The home has a comprehensive complaints procedure that is also available in sign. The home has received one complaint since the last inspection but was not related to the home and the manager passed the complaint onto the relevant department. Several thank you notes were seen displayed during this inspection and the home also kept a book for compliments received and there were several recorded. The home has a comprehensive adult protection whistle blowing, gifts and legacies policies and procedure in place received via Plymouth City Council. The home also has in place a physical restraint and restriction of liberty policy. The manager records all incidents of verbal and physical abuse. And risk assessments are based on and agreed by a multi disciplinary team. All staff have received training on dealing with aggression and breakaway advise. Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 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 standard(s) 24/25/26/27/28/29/30 The home continues to maintain a suitable environment for its stated purpose. EVIDENCE: The premises were accessible to all the service users, comfortable, well furnished and decorated, clean and light. Some rooms had been re-decorated since the last inspection. The home kept a property diary where small tasks that needed doing, and actions taken, were recorded. The home employs a maintenance person and the home has a planned maintenance and renewal programme for the fabric and decoration of the premises. Local amenities and public transport were accessible by service users with support from staff. 2 of the rooms are under 10 sq m and the manager has plans to change one of these rooms to a office and alter the rear of the property to include another bedroom. The home no longer has any shared bedroom. As the home provides respite only service users usually only stay for a few days or weeks and the bedrooms were decorated individually but possessions were few due to the home only providing respite care. All bedrooms now contain lockable storage space and bedroom doors were fitted with appropriate locks. One of the bedroom doors had an alarm fitted, which activated a light to alert staff when a particular service user left the bedroom. These devices were rarely Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 18 used and only and the use was documented and kept under review. Risk assessments were carried out in conjunction with the service user, relatives/representatives and any other relevant professionals. The home has four bathrooms one containing a shower bed on the ground floor. There are six toilets including a disabled facility. All bathrooms and toilets were lockable and could be opened from the outside in an emergency. The home has plenty of communal areas and the Manager stated that there are proposals to alter the internal arrangements of rooms. There is plenty of outdoor space in the garden. The kitchen and laundry facilities were found to be satisfactory. Clean linen is now stored elsewhere as recommended in the last inspection report, and sleeping in staff have a bedroom on the 1st floor. Service users may smoke in the resource room or outside in the garden. The home has specialist equipment including hand/grab rails, a shower bed, two mattresses for use on the floor rather than hospital beds or bedsides, a disabled toilet facility and a ramp to the front and side entrances met the needs of the service users. The home had level access throughout the ground floor and the garden was accessible. The home had a call alarm system in place in parts of the home. The home has plenty of symbols, pictures and photographs to facilitate communication with service users, which demonstrates excellent practice. The premises were found to be clean, hygienic and free from offensive odours. One room had a slight odour but the manager is addressing this and the room had been re-decorated. Laundry facilities were found to be satisfactory and there is a coded lock on the door following the outcome of a risk assessment of service users. The washing machine had a sluice facility. The home has an infection control policies and procedure and the manager confirmed that all staff received training in infection control. The home used a local contractor for the disposal of clinical waste. Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31/32/33/34/35/36 The Registered Manager promotes and supports staff training to ensure the service users receive a good service. EVIDENCE: Discussions with the management team indicated that the staff understood their roles and responsibilities. The home has a clear induction procedure that include information on the policies and procedures of the home. 14 of the 19 staff have already gained a NVQ level 2 or above in care. 1 staff member is working towards their NVQ and 1 staff is undertaking the LDAF award. A discussion with the Manager confirmed that staffing was flexible due to the different numbers and needs of service users who were resident at any one time. The home uses Plymouth City Council recruitment procedure to ensure that all new staff employed is suitable for employment. At times the home does use agency staff. The home always has an Assistant Manager on duty 24 hours a day, who sleeps in at night. The home employs domestic staff, two cooks who worked on different days, a clerical officer and a handyman. Case tracking provided evidence that service users care plans use specialist services when necessary. The home holds regular staff meetings and minutes were kept. Most staff records were kept on the premises. And all new staffs files seen are complete with the records required to meet this standard. Staff that Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 20 have been employed for some time have their files held with Plymouth City Council. As stated in the pre-inspection questionnaire all Criminal Records Bureau checks are carried out. All staff appointments were subject to a sixmonth probationary period. The homes training files were seen and the manager was keen for the staff to complete training. Staff induction was seen and comprehensive in detail and the manager checks with Plymouth City Council training department and felt that this induction was relevant for the home. Supervision records were seen and staff has completed appraisal forms on file as recommended from the last inspection report. The inspection witnessed a handover between 2 assistant managers and all relevant information was passed over. Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37/39/40/41/42/43 The management of this home is very good and ensures that the records are maintained and that the staff had regular and updated training to meet the service users needs. EVIDENCE: The Manager has now completed her Registered Managers award and has a NVQ 4 in Care and Management. The quality assurance policy was seen in place and the inspector saw a completed questionnaire for service users and parent/carers. The manager has plans to complete the visiting profession at a later date. The audit would be completed and relayed to the parent/carers meeting at a later date. The announced inspection outcome would also be given at this meeting. The homes policies and procedures were comprehensive and available to all staff. The policies held were from Plymouth City Council policies with some adjustment for individual homes when and were needed. The service users have access to all policies and procedures. Record keeping Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 22 was found to be satisfactory. The Registered Manager and the written policy confirmed that service users may have access to their records if they wish. One of the assistant managers has the responsibility for all health and safety issues. There were policies and procedures in place to cover all aspects of health and safety issues and practices described and observed were found to be satisfactory. The inspector was informed that all staff were trained in manual handling and moving and handling assessments were documented. Fire safety tests, checks and staff training were being carried out as required. The fire alarm system was serviced by a local contractor. All staff were trained in emergency procedures and emergency first aid and there was always a qualified first aider on duty. All staff had attended training courses on basic food hygiene and fridge/freezer and cooked food temperatures were being documented. There was a cleaning rota in the kitchen. Overall, infection control practices, policies and procedures were found to be satisfactory. Substances hazardous to health were stored safety, COSHH assessments were up to date and data sheets were available. Gas, heating, and electrical appliances were checked regularly by a contractor. The boiler was checked regularly to ensure that hot water was stored and distributed at the correct temperatures. A risk assessment for Legionella had been carried out and documented. Thermostatic valves had been fitted to all hot water outlets and the home had a written bathing policy and procedure and thermometers were available in bathrooms. The temperature of the hot water from all hot water outlets was tested monthly and the results recorded. All radiators and pipe work were now guarded. All window openings were restricted. There was a written accident policy and procedure and all accidents and incidents were recorded. Detailed risk assessments had been carried out for all safe working practice topics. Plymouth City Council produces annual plans regarding business and financial planning and these are avaliable on request. And the Manager was actively involved in budget monitoring. Insurances were arranged by Plymouth City Council and a copy of the employer’s liability insurance was on display. Lines of accountability within the home were clearly understood by service users and staff. Copies of this year’s monthly provider visit reports were provided to the Commission for Social Care Inspection. Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 4 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 4 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 4 4 3 3 Standard No 31 32 33 34 35 36 Score 3 4 4 3 4 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Welby Community Unit Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 4 x 3 3 3 3 3 D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 24 no 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 Regulation Requirement Timescale for action 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 39 Good Practice Recommendations The home should expand the quality assurance questionaire as discussed to include visiting professional. Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Welby Community Unit D52-D04 S31273 Welby V222461 300605 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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