Inspection on 11/12/06 for Welcome Care Home Ltd

This inspection was carried out on 11th 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 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

Welcome Care Home Ltd 23/07/08

Welcome Care Home Ltd 31/07/07

Welcome Care Home Ltd 24/02/06

Welcome Care Home Ltd 04/11/05

Welcome Care Home Ltd 15/11/04

Welcome Care Home Ltd 13/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Welcome Care Home Ltd 26-28 Fordel Road Catford London SE6 1XP Lead Inspector Pauline Lambe Unannounced Inspection 09:50 11 December 2006 th 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 Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Welcome Care Home Ltd Address 26-28 Fordel Road Catford London SE6 1XP 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) 020 8697 5024 Mrs Margaret Newland Mrs Margaret Newland Care Home 15 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (0) Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 15 persons whose primary needs are old age and dementia 24th February 2006 Date of last inspection Brief Description of the Service: The Welcome Care Home is registered to provide personal care and accommodation to a maximum of 15 older people suffering from dementia. The overall aim of the home is to provide care and support in a homely environment with a relaxed family atmosphere. The underlying philosophy, stated in the home’s brochure, is that of a holistic approach to care. The registered provider is a company belonging to Mrs Margaret Newland, who is also the registered manager for the service. The staff team comprised of a registered manager, a deputy manager, care staff and some domestic hours. The home was opened in 1993 and consists of two semi-detached Victorian houses, which have been joined into one. There is a rear garden with a patio, a fishpond and a lawn area, which is well maintained. Thirteen of the home’s bedrooms are single with en-suite toilet facilities. There is one shared room, which has a wash hand basin only, but exclusive use of a nearby toilet. There is a passenger lift and a short stair lift to ensure access to all parts of the house. The property is situated in a residential road in the Catford area, with some local shops nearby and is close to Catford town, public transport and local amenities and shops. The current fees ranged from £435 - £450 per week and residents paid privately for items such as toiletries, newspapers and personal purchases. Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this unannounced inspection was completed over 8 hours on 11th December 2006. The manager and staff assisted with the inspection. Thirteen residents were in the home and two were in hospital. The service was last inspected on 24th February 2006. The inspection included a review of information held on the service file, a tour of the premises, and inspection of records, talking to residents, relatives, staff and the manager and reviewing compliance with previous requirements. It was noted that efforts had been made to address the requirements and recommendations made in the last inspection report. Residents and relatives were satisfied with the quality of the service provided. What the service does well: What has improved since the last inspection? What they could do better: Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 6 The registered person must confirm in writing that based on assessment the home is suited to meeting the needs of a prospective resident. Care plans must be kept up to date and the most recent ones available to care staff. Personal hygiene care and activity records must be kept up to date. All records must be fully dated and correction fluid must not be used to make corrections to record entries. Records must be kept for homely remedies brought into the home. The homely remedy list must be reviewed with the GP. Internal and external medicines must be stored separately and the temperature of the medicine storage room must be monitored. A maintenance and refurbishment programme must be prepared for the property and a copy sent to the Commission. Repairs identified in the report must be addressed. More attention must be given to keeping the environment clean. The staff roster must show all staff including the manager on duty at any time and show who covers the sleep in shift. A system must be in place to monitor hot water temperatures. Radiators accessible to residents must have protective covers fitted and risk assessments must be in place in relation to the decision not to restrict window openings above the ground floor. 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. Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and standard 6 did not apply. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Residents had an assessment of need completed prior to admission. Residents had received confirmation that based on assessment the service was suited to meeting their needs. EVIDENCE: The registered manager together with the deputy manager completed an assessment of resident needs before accepting their referral to the home. The manager said that care managers also completed resident assessments. A long term assessment of resident needs was completed at the time of admission. Residents were invited to have a ‘trial visit’ to the home before accepting a placement. The registered person had not confirmed in writing to residents that based on assessment the service was suited to meting their needs. Requirement 1. The service did not provide intermediate care. Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 to 10. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. Individual care plans were prepared for residents and some improvements were needed to these. Residents were supported to access healthcare services. Although systems to manage medicines were satisfactory there were some areas that required improvement. No concerns were noted or raised by residents in relation to how staff respected their privacy and dignity. EVIDENCE: Three resident care records were viewed. These included care needs assessments, risk assessments and care plans. Where possible care plans were prepared with the involvement of the resident and or their relative. The deputy manager said that the more recent care plans were kept on the computer. However as the computer was not available to care staff these were not seen and were not considered very beneficial to staff providing care. The care plans seen reflected the needs of the residents and showed how these were to be met. However it was not clear from these that the care plans were reviewed monthly. The deputy manager said that this was reflected on the computer records. Care records included a monthly record chart to show what personal care had been given for example a bath, a shower and hair wash and Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 10 a monthly activity record chart was also kept to show what activities the resident had attended. However these records had not been dated and had not been kept up to date. For example some had been completed for half the month and some had not been completed at all in some months. A number of records seen had been corrected using correction fluid. Requirement 2. All residents were registered with a GP. On the care plans seen there was evidence to show that health needs such as dental care, GP visits, vision care and chiropody were made available to the residents. Staff said they when needed they requested visits from a district nurse team or accessed other medical support through GP referral. Policies and procedures were provided in relation to medicine management; however these did not include how to manage medicine errors. None of the residents managed their own medicines. One resident took responsibility to self-administer their Insulin. This was drawn up by the district nurse and stored in the domestic fridge in the kitchen. Following the inspection the inspector confirmed with the Commission pharmacy inspector that this practice was safe and a copy of the Royal College of Nursing guidance on the management of Insulin was sent to the registered person. A record was kept for medicines brought into the home, administered and returned to the pharmacy. The returns record was not seen and the inspector was told that this was with the pharmacist. Administration records were well maintained and those seen for two residents were correct. A supply of homely remedies were kept and a list agreed with the GP. This list was prepared in 1999 and should be updated. Only one homely remedy medicine was in stock but there were no records to show when or how many of this was obtained, the medicine had been removed from its original packaging and there were no record of administration. Internal and external medicines were stored together. Medicines were stored in a locked cupboard in the dining room but the temperature of this room was not being monitored. Requirement 3. Residents spoken with during the inspection did not raise concerns as to how staff treated them. Residents presented as relaxed and comfortable in the home and staff were observed interacting appropriately with them. Feedback from relatives supported this. Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 to 15. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. Residents seemed satisfied with their lifestyle and were supported to maintain contact with family and friends. Where practical residents were involved with making decisions about their lifestyle. Meals were satisfactory but attention was needed to the standard of hygiene of the kitchen and recording of food and food storage temperatures. EVIDENCE: Care plans seen showed how resident needs were to be met including social and leisure needs. An activity record chart was seen in the resident files viewed. However these had not been kept up to date, so did not support the implementation of the activity care plan. The daily evaluation records seen gave limited information in relation to the resident’s day-to-day care and social life. Residents spoken with were satisfied with their lifestyle. A number of residents attended church regularly but in the view of one relative the ethos of the home was ‘overly religious’. There were a number of religious pictures displayed in the communal areas and bedrooms. On the day of the inspection a number of residents were sitting in the conservatory. Both the television and a resident’s personal music were on together. This could be disorientating for some residents and staff should monitor the effect of this on the residents. Maybe the resident who enjoyed their own music could spend some time in Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 12 their bedroom listening to this to give other residents a break. Requirement 4 and recommendation 1. The home had an open visiting policy and relatives and friends were welcomed when visiting. Residents said they enjoyed family contact and some made visits to their family homes. The ability of residents to make informed decisions about their lives varied. Some were capable of making their own decisions about how they spent their time while others were unable to do this. Care plans seen showed that where practical residents were involved with preparing these and where this was not practical relatives were involved in care planning. Residents presented as content and relaxed in the home during the inspection. The care staff prepared and cooked residents’ meals. A two weekly menu was provided for lunch and supper. There was no choice of food for either meal and no vegetarian dishes included. One relative said that the lack of vegetarian dishes was a problem for their relative. Staff said that residents could choose an alternative to the menu if the meal was not something they liked. During lunch staff were attentive to residents’ needs, gave assistance where needed and residents seemed to enjoy the meal but there were no condiments on the dining tables. Systems were in place to record food, fridge and freezer temperatures but the records had not been kept up to date. A cleaning schedule was also in place for the kitchen but again this had not been kept up to date and was last completed in June 2006. The kitchen needed some attention such as repainting and attention to high dusting. Residents spoken with seemed generally satisfied with the meals provided. Food store supplies were limited and staff said that this was because food tended to be bought almost on a daily basis. Requirement 5. Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Satisfactory systems were in place to manage complaints and the protection of vulnerable adults. EVIDENCE: A complaints policy and procedure was provided and included timescales for investigating complaints made about the service. Residents and relatives spoken with said they knew how to make a complaint and indicated they would feel comfortable doing this. No complaints had been made about the service to the registered person or the Commission since the last inspection. A policy and procedure was provided in relation to adult protection. The procedure should state clearly that all suspicions or allegations of abuse must be referred to the local authority for investigation under their procedures. A copy of the local authority’s adult protection procedures was not provided and it was the inspector’s view that this should be available to staff. Staff spoken with had a good awareness of adult protection and how to manage an allegation or suspicion of abuse. Recommendation 2. Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 23 and 26. Quality in this outcome area was poor. This judgement has been made using available evidence including a visit to the service. The property would benefit from redecoration and refurbishment. The environment is quite dark and the décor dated. Adequate bathing and toilet facilities were provided but these areas also required some attention. Many windows above the ground floor did not have restricted openings and there were no risk assessments seen to support this decision. Overall the standard of hygiene in relation to the environment must be improved. EVIDENCE: The proprietor of the home was responsible for routine maintenance in the home, which was adequately decorated and maintained. Staff recorded repairs in a book and a maintenance person was contracted to carry out the repairs. The system in place ensured that once repairs were completed this was indicated in the maintenance record book. The home would benefit from a total review of the environment as it was noted that in some areas floor boards had ‘dipped’, the décor was dark and dated, furniture items such as arm chairs needed to be replaced and some areas of the carpet were damaged. Therefore Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 15 a requirement has been made to provide the commission with a planned maintenance and refurbishment programme for the property. Requirement 6. The property had two communal bathrooms and four separate toilets. The bathroom on the ground floor needed a deep clean and the flooring round the fixed hoist needed repair, as it was no longer watertight. The shower room on the first floor was satisfactory but the radiator was very hot and did not have a protective cover. The window in this room did not have restricted openings. Requirement 7. Bedrooms seen were satisfactory and residents spoken with said they were satisfied with their private and communal space. A number of bedroom doors were held open with wooden wedges. Some net curtains seen needed to be washed. There was an unpleasant odour in bedroom 15. Bedroom 14 was very cluttered and untidy and the bed linen was quite stained. Many of the bedroom windows on the first and top floor did not have restricted openings. Requirement 8. Overall the standard of hygiene in the home could be improved. Bathrooms and toilets needed a deep clean and attention was needed to other areas in the home such as woodwork, light switches, high dusting and washing net curtains. Consideration must be given to increasing the number of staff hours allocated to cleaning and domestic tasks. Care staff were responsible for doing the cooking, the laundry, and most of the cleaning as well as providing care and organising activities for residents. Requirement 9 and recommendation 3. Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 to 30. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. Adequate staffing levels were maintained but some improvements were needed to the roster recording. Over 50 of care staff had achieved NVQ 2 qualification or above. Recruitment procedures required some improvements to ensure they fully comply with regulation. Staff should have access to a minimum of three days training a year. EVIDENCE: The staff team comprised of a registered manager, a deputy manager, care staff and some staff domestic hours. A written staff roster was kept to show which staff were on duty at any time. At night one waking and one sleeping member of staff were on duty. The staff roster did not include the full name of the employee, did not show when the manager was on duty and did not show which employee slept over at night. The registered person accommodated care students who were completing NVQ training. When on duty the students were supervised by the person in charge of the shift. This also applied to a volunteer who assisted in the home. The manager checked that all students and volunteers had up to date CRB and POVA checks before working in the home. Residents or relatives did not raise any concerns about staffing levels in the home. Requirement 10. The manager and deputy manager were both qualified nurses and nine care staff had achieved NVQ level 2, which was over 50 of care staff. Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 17 Recruitment policies and procedures were provided. No new staff had been employed since the last inspection. Four employee and one volunteer personal files were viewed. These were generally well kept and included most of the information required by regulation. All files included evidence of CRB and POVA checks. Some hand written references seen had not been verified as genuine. None of the files had a recent photo of the employee. One file had only one written reference and one did not have a health statement. Requirement 11. In the employee files seen there was evidence to show that staff received supervision and training. However not all files seen showed that the employee had received 3 days training in the last 12 months. Staff said they received adequate training to enable them to fulfil their roles. Records seen showed that during 2006 staff had access to training such as health & safety, food hygiene and NVQ. All staff received training on dementia care in 2004, basic first aid and adult protection in 2005 and moving & handling in 2004. Recommendation 4. Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. The manager had the qualifications and experience needed to manage the service. Efforts had been made to introduce a quality assurance system. Satisfactory systems were in place to manage residents’ personal allowances. Although attention was given to providing a safe environment some improvements were needed in this area. EVIDENCE: The home’s manager was registered with the Commission and had the experience and qualifications needed to manage the service. The manager was a registered nurse, had achieved NVQ 4 qualification in care and management and was supported by a deputy manager who was also a registered nurse and who has worked in the home over a number of years. Residents spoken with said they were happy with how the home was run. Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 19 No relative meetings were held. The manager said that staff tended to work closely with relatives to ensure residents had a lifestyle that suited them. Resident and staff meetings were held together which again the manager said worked in the best interest of the residents. No minutes of these meetings were available to view. The manager completed a quality assurance audit in April 2006 by sending out satisfaction questionnaires. This showed a general satisfaction with the service. It was unclear if a copy of this audit was sent to the Commission or if an improvement plan had been implemented based on the findings of the audit. Recommendation 5. Management were not responsible for any of the residents’ benefits or bank accounts. Residents or their families managed this. Management did offer assistance with managing residents’ personal allowance. This money was held in a resident bank account and receipts were kept for money received and spent. All except one resident had access to their personal allowance and the manager was in the process of sorting out finances for this resident. A selection of safety records were viewed. These included fire safety, bath hoist, gas safety, electricity and accident records. Fire drills were held at regular intervals. An environmental health inspection was completed in January 2006 and the manager said that all the issues raised had been addressed. One accident had been recorded since the last inspection. There was no system in place to monitor hot water temperatures and as mentioned many windows above the ground floor did not have restricted openings. Also not all radiators had protective covers fitted. Requirement 12. (See also requirements 5,7 and 8). Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 X 2 X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP4 Regulation 14 Requirement Timescale for action 12/02/07 2. OP7 15 3. OP9 13 The registered person must confirm in writing to residents that based on assessment the home is suited to meeting their needs. The registered person must 12/02/07 ensure that: • Care staff have access to the most up to date care plans for residents • Care records are kept up to date and fully dated. • Staff do not use correction fluid to amend errors made to record entries. The registered person must 12/02/07 ensure that: • Records are kept for all medicines brought into the home. Records must be kept for receipt, administration and disposal of homely remedies. • That the temperature of the medicine storage area is monitored to ensure safe storage. • That internal and external medicines are stored separately. DS0000025650.V291982.R01.S.doc Version 5.1 Welcome Care Home Ltd Page 22 4. OP12 17 5. OP15 16 6. OP19 23 7. OP21 23 8. OP24 23 9. OP26 23 That the homely remedy list agreed with the GP is reviewed and updated. The registered person must ensure that resident care records such as activity records and daily care records are kept up to date to reflect the care given and the resident’s access to leisure activities. The registered person must ensure: • Residents have a choice of meal at lunchtime. • Resident’s special dietary needs are catered for. • The kitchen is kept clean and is repainted. • That food, fridge and freezer temperatures are recorded daily. The registered person must ensure a maintenance and refurbishment programme is in place for the property and a copy sent to the Commission, which includes planned start and completion dates for work identified. The registered person must ensure bathrooms and toilets are kept clean, the repairs to the flooring in the bathroom on the first floor are completed and the radiator in the shower room has a protective cover fitted. The registered person must ensure that the decision not to restrict the window openings above the ground floor is supported by relevant risk assessments. Door wedges must not be used to hold fire doors open. The registered person must ensure all areas of the premises are kept clean at all times including washing of net DS0000025650.V291982.R01.S.doc • 12/02/07 12/02/07 12/02/07 12/02/07 12/02/07 12/02/07 Welcome Care Home Ltd Version 5.1 Page 23 10. OP27 17 11. OP29 19 12. OP38 13 curtains. The registered person must ensure the staffing roster record includes the full name of the employees, times when the manager is on duty and show which employee slept in at night. The registered person must ensure that all the information required by regulation and schedule 2 is obtained for staff before they start working in the care home. The registered person must ensure a system is in place to monitor hot water temperatures. All radiators accessible to residents must have protective covers fitted. 12/02/07 12/02/07 12/02/07 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 OP10 Good Practice Recommendations The registered person should ensure resident privacy is respected. Items such as ‘bath lists’ with dates and resident’s names should not be displayed in communal areas of the home. Staff should monitor the noise levels in the conservatory and ensure that both the television and music are not on at the same time. The registered person should ensure the procedure for adult protection clearly states that all allegations or suspicions of abuse are reported to the local authority. A copy of the local authority policy and procedures in relation to adult protection should be obtained and made available to staff. The registered person should give serious consideration to increasing the domestic hours allocated to cleaning and domestic tasks in the home. The registered person should ensure all staff receive three DS0000025650.V291982.R01.S.doc Version 5.1 Page 24 2. OP18 3. 4. OP26 OP30 Welcome Care Home Ltd 5. OP33 days training a year. The registered person should ensure minutes are kept for meetings held with residents and staff and that an action plan is developed to improve the service based on the outcome of a quality assurance audit. A copy of any such audit, action plan and report should be sent to the Commission. Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Welcome Care Home Ltd DS0000025650.V291982.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!