Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 18/07/07 for Welland House

Also see our care home review for Welland House for more information

This inspection was carried out on 18th July 2007.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The strongest field of the service was the respect for service users privacy and dignity. All service users and staff spoken to confirmed the inspector`s observation finding that the relationship amongst service users and staff was respectful, friendly but professional, and created an atmosphere where service users were encouraged to remain as independent as possible. The service user said: "I don`t like too many of activities. I prefer to stay here, in my room, and to watch my TV. They (staff) always offer if something is going on, but they respect my choice to stay here." Her daughter, a visitor, added: "I like to get a newsletter. They keep me informed about what is going on in the home and always tell me about mum. I think in general, they are kind and this is a good place to be." The staff benefited from a good atmosphere and support provided, not only from the management, but also from mutual floor staff`s support. A good and thorough recruitment procedure ensured the protection of service users.

What has improved since the last inspection?

The home reviewed their statement of purpose and service user`s guide as a part of their change of registration. They changed their registration category and increased the number of service users with dementia to 17, to accommodate changes in users` conditions. The manager was also registered with the CSCI, the registration and inspection authority, since the last inspection. The home improved the frequency of care plan reviews. A new summary of care plans was designed. This new brief was used for getting a quick overview of needs for individuals that needed to go to hospital and for visiting professionals to see the users` needs in brief. This brief was also placed inside each user`s cupboards where it could provide immediate information to potentially engaged agency staff. Although medication records were improved, as required on the last inspection, there were other medication issues that needed attention and that are addressed in the next section of this report. With the effort of the cleaning team and with the replaced carpet in a specified room, the home no longer had any areas affected by bad smells.

What the care home could do better:

Although the care plans were significantly improved, the use of the first person in describing how the needs could be met was not appropriate in all cases and the manager stated that she would arrange for reviews and alterations where needed. Based on inspection of 5 files, there were inconsistencies in care plans and records. Some were good, but some lacked signatures and review dates, some were accurate, but some contained errors, as was the case with one weight chart. However, the main problem lay in the area of dealing with medication and this process needed an urgent and thorough review. The current system presented a risk to service users. Although the staffing level on the papers seemed appropriate, the observation of care processes showed a lack of staff. In discussion with the manager it was agreed that action would be undertaken to correct the problem and ensure better service to the service users. It was also agreed that decisions concerning service users suggestions related to food need to be explained to the individuals, if the home was not able to implement the suggested individual proposals.

CARE HOMES FOR OLDER PEOPLE Welland House Poplar Avenue Dogsthorpe Peterborough PE1 4QG Lead Inspector Dragan Cvejic Key Unannounced Inspection 18th July 2007 09:00 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 Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Welland House Address Poplar Avenue Dogsthorpe Peterborough PE1 4QG 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) 01733 345421 01733 563209 cathy.wiseman@peterborough.gov.uk Greater Peterborough Primary Care Trust Mrs Catherine Wiseman Care Home 54 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (17), Old age, not falling within any other of places category (37), Physical disability (3) Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th February 2007 Brief Description of the Service: Welland House is situated in the Dogsthorpe area of Peterborough. The home is a single storey building which has been purpose-built and offers accommodation to up to fifty-four elderly people of both genders. Built about twenty years ago, the home is divided into six self-contained units, each comprising lounge, dining and kitchen areas, single bedrooms, bathrooms, toilets and a sluice. An extension, registered in 2004, has four single rooms, each with an ensuite toilet, washbasin and shower, as well as a lounge/dining room with a kitchenette area. There is a large lounge in the centre of the home, a main kitchen, laundry, offices and staff facilities. The home is set in pleasant gardens and is within walking distance of local shops, pubs and churches, and a few minutes drive from the centre of the city of Peterborough. Good road and rail services link Peterborough to London and other major cities. The fees charged range from £343.19 a week to £413.28. People using the service for respite care are charged £84.00 a day. The reports published by the Commission are available in the entrance hall and individuals can be given their own copy if they request. Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. It was triggered by recent reports of three medication errors and previous poor grading of the service. The inspection was carried out during the morning hours and lasted for 4 hours. The inspector talked to 5 service users, observed a staff member administering medication, talked to a relative, to 4 staff members and to the manager. Five service users’ records were checked, two staff records, the health and safety file and medication records. The inspector briefly met the responsible individual, a higher manager, who also had his office in the home. A tour of the home provided information about the environment. The main methodology used was case tracking, by which 5 service users were observed, spoken to and their files checked. The other method used was A Short Observation Framework for Inspectors, SOFI, that was used for 30 minutes and by which a service user and staff were observed for 30 minutes. Discussion with the manager provided not only evidence for this report, but also information about her plans for the improvement of the service and provisions. What the service does well: What has improved since the last inspection? The home reviewed their statement of purpose and service user’s guide as a part of their change of registration. They changed their registration category and increased the number of service users with dementia to 17, to accommodate changes in users’ conditions. Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 6 The manager was also registered with the CSCI, the registration and inspection authority, since the last inspection. The home improved the frequency of care plan reviews. A new summary of care plans was designed. This new brief was used for getting a quick overview of needs for individuals that needed to go to hospital and for visiting professionals to see the users’ needs in brief. This brief was also placed inside each user’s cupboards where it could provide immediate information to potentially engaged agency staff. Although medication records were improved, as required on the last inspection, there were other medication issues that needed attention and that are addressed in the next section of this report. With the effort of the cleaning team and with the replaced carpet in a specified room, the home no longer had any areas affected by bad smells. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Welland House DS0000035292.V347064.R01.S.doc Version 5.2 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 Welland House DS0000035292.V347064.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensured that proper assessments were carried out and that service users had enough information to make their own decision about their choice of home, knowing that their needs will be met. EVIDENCE: The home reviewed their statement of purpose and service user’s guide to present the increased number of registered spaces for service users with dementia and the new manager’s registration. Three service users spoken to confirmed that they could choose the home and that they had enough information. Five service users’ files were checked and the initial assessment documents were present in all. Two recent ones had more details than the three older ones. Showing that initial assessment was improved. The assessed topics covered all areas of service users’ lives. Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 9 “Yes, they meet my needs. I have a bath three times a week”, stated the service user spoken to. “They send me an updated care plan every month. They are very good with my mum”, added a visitor, the daughter of a service user. Files checked confirmed that users’ needs were met. The manager added: “We cater for a service user on a gluten free diet.” The files also contained a written letter to prospective users stating that the home was capable of meeting their needs. Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Despite showing respect to service users and offering good personal care, the medication risk determined poor outcomes in this group of standards. EVIDENCE: Five service users’ files were checked. Care plans were written in the first person that intended to give an impression of service users’ involvement. This principle was undermined with a plan stating: “I am on a 20 minute check”, and some other comments that obviously were not made by service users. The manager agreed to arrange alterations of inappropriate entries. Risk assessments were part of care plans and addressed significant risks related to in care plans. Inconsistency was found among these five care plans. One did not have a place for the service user to sign. However, her review sheet was signed. In Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 11 the other, the weight chart was not accurately recorded, as two entries did not make sense. The other three charts in other files were accurate. Some reviews were regular, once a month, but some changes recorded on the care plan did not have date and signatures and were difficult to connect with the signed review sheets. A relative spoken to confirmed that she was sent a review sheet monthly and was quite pleased to be able to follow the implementation of the care plan for her mum. Personal and health care needs of service users were met. A service user stated, sitting in her armchair: “They are good. They help me with all my personal care.” Another user commented: “Personal care is very good. My regular carers know my needs and help me.” Appropriate charts were kept for individuals that needed special attention in assessed areas of their needs. The examples of charts included: weight charts, fluid intake chart and observation chart. Medication process was not safe. The home reported 3 medication errors since the last inspection. During the site visit, a staff member discovered that there was no prescribed medication for one user. The process was observed for 40 minutes. A staff member was the only one present in the unit and had to prioritise and stop administering medication in order to respond to a call and help another user. The staff member did a brilliant job, being patient, friendly, but professional; but being on her own in the unit at that time meant that service users had to wait, even to be taken to the toilet. Records were improved, the checked records did not have any gaps. The manager explained the plans to change medication supplier and introduce a new supplier’s system, but, at the time of site visit, there was no evidence to show improved outcomes to service users. Privacy and respect for dignity of service users was a very strong area of care that the home offered. Staff were observed talking to users in a friendly, but professional way. The users praised staff for their patience, and for respecting them and their privacy. The level of respect exceeded minimum standards. Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users had an influence on daily routine in the home and the choice to join activities if they wanted. Mealtimes were relaxed and food in general was good. EVIDENCE: “I don’t like too much of activities. I prefer to stay here, in my room, and to watch my TV. They (staff) always offer if something is going on, but they respect my choice to stay here,” stated a service user. Another service user spoken to also confirmed that the home provided activities and offered the choice to service users to join in if they wanted. Daily life routine was very much influenced by users wishes, expressed during their meetings. The home issued a newsletter where suggestions were made and then consulted users on their preferences. A staff member explained that she started giving medication a bit later than the instructions stating 8am, as most users in that unit wanted to stay in bed longer. This fact did not affect the timing between two doses, but when the Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 13 administering process was held up or delayed by responding to the needs of other service users, a lack of active staff in that unit resulted in an extended time to complete medication round. Care plans recorded service users interests and the new brief description also contained references to users likes and dislikes. Some service users were going out to local shops independently. There was good contact with the school nearby, the manager stated. Service users were encouraged to remain financially independent with support from their families if they needed it. Those that needed further assistance were helped by social services and not the home. The home did help some users to keep small amounts of their personal allowances in their safe and related records were checked and were accurate. Most comments received graded food as good. There were some suggestions on how to further improve choice of food. However, menus varied and showed a balanced diet. Records in two files showed that users could choose alternatives if they were not happy with the main courses recorded on menus. An improvement that could easily be done was discussed and the manager undertook to put it into practice: if a service user suggests something that is not workable, he/she will get explanation from the manager. Breakfast was observed and three service users ate what they wanted in a pleasant, sociable atmosphere. Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had in place policies and procedures and working practices that ensured the protection of service users. EVIDENCE: The manager stated that the home had not had any formal complaints. However, she added that concerns and comments were acknowledged, dealt with and answered. Three service users stated that they would complain if they wanted to and knew the procedure. A visiting relative stated that the instruction of how to complain was published in a newsletter. The Council carried out their investigation of the case of one service user and concluded the investigation with the referral to the POVA register, but the case was in relation to external process and did not have a direct connection with the home. The positive approach of the home was to be informed about something that related to the general welfare of their service user. Appropriate protection policies and procedures were in place, including thorough checks of staff within the recruitment process. Medication risk is addressed in another section of this report. Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offered a clean and well maintained, well equipped and comfortable environment that service users appreciated as their own home and felt comfortable and free to use all parts of the home. EVIDENCE: The tour of the home demonstrated a nice, pleasant and comfortable environment for service users. Three service users spoken to were satisfied with the comfort both of communal areas and personal bedrooms. The units designated for dementia were assessed by the manager for this purpose and she found them appropriate. Service users were moving freely throughout the home. The presence of a day centre, next to the entrance of the home was not intrusive to service users, Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 16 but provided another option for users to move freely through the entire home if they wanted and to meet some friends and join organised activities. Outdoor space was provided in several areas around the home, offering a secluded and secure space for people with dementia and allowing users whose risk assessments indicated smaller risk to go out unsupervised if they wanted. The carpet address on the previous inspection was replaced and the home was free from offensive odours. A visitor and a service user graded cleanliness as “generally good.” They have both noticed that the cleaning took longer on the day when the machine for washing carpets broke and “they had only that one machine, so it took longer to complete cleaning.” Industrial equipment in the laundry helped maintain infection control at a safe level. The home used the “Otex” system to ensure infection control was in place. Health and safety was regularly checked by the higher management team member, a responsible individual, who visited and the inspected home once a month. Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In spite of staff skills, knowledge and number, there were times when staff could not respond timely to service users’ needs, mainly due to improper organisation. EVIDENCE: “It sometimes look as if there is not enough staff”, stated a visitor and was supported in this statement by her mother, a service user. The manager stated that 10 carers per shift exceeded the minimum number required. Observation by the inspector confirmed that the needs of service users were not always met at the right time and that the staff needed to be better organised to meet the needs of service users. A service user needed to wait, either to be helped to go to the toilet, or another user would need to wait to get all prescribed medication. A staff member who administered medication had to prioritise and complete both tasks, while her colleague was away in another unit collecting sheets. Two staff members in the dementia unit were not able to respond to a call by another user, as they were helping a user who needed two carers. About 50 of staff were NVQ trained and there was a plan for a further intake from September. Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 18 Training was well organised and the majority of staff were up to date with all mandatory subjects. The staff spoken to stated that training was good and they felt confident to do their jobs. A service user and a visitor commented that, in their opinion staff training was good and staff had sufficient knowledge to help them do their jobs. The home followed strict recruitment procedure and ensured proper checks were carried out prior to staff starting work independently. Two staff files were checked and confirmed these statements. All checks were documented in staff files. Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32.33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the service was restructured and enlarged in order to provide better support to staff and consequently to service users. However, the results and the outcome were still to be seen. The atmosphere exceeded standards but safety for the users still needed to be improved. EVIDENCE: The manager was registered since the last inspection. However, she would need to complete her plan for improvements of the service to the level that service users could feel the improvements and the outcomes of changes spread to all areas of users’ lives. The increased management team by introduction of 3 assistant managers brought an improvement in supervision Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 20 frequency, in better communication and better support to staff, but the outcomes for service users were still to be seen. Increased staffing level to respond to the increased number and needs of service users with dementia was planned. Each dementia unit was planned to have at least 2 staff members on duty in these units at all times. The atmosphere in the home helped keep respect for service users above minimum standards. Users felt free to give comments and suggestions. Planning how the service runs was done, but the effects and outcomes were still to be seen in more than just a few areas of users’ lives. Equal opportunity was promoted through daily life and recruitment procedure. The home employed a mixture of female and male staff to respond to the wishes of service users to be helped by the specified staff’s gender. Full checks were made for a staff member coming from Estonia. Quality assurance process was on going. The home chose a specific topic each month to assess the standard of the service. Topics covered included food, staffing, dignity etc. Service users accepted on respite – short stay care- were consulted on a separate, specially designed questionnaire. Results of the surveys were assessed every 3 months by the manager, who reported them back. The results were incorporated into a plan for improvement, but the comments remained anonymous. The home in general did not deal with service users’ money, apart from keeping small amounts of their personal allowances. The records for this were accurate in 3 checked cases. Staff supervision was much better and more frequently organised. The records showed that staff received 3 supervision sessions half way through the year and were up to date with planned process. Health and safety procedure were followed and were checked monthly by the responsible individual. This higher manager provided comments and requirements directing home to improve identified areas. However, the service users were at risk due to current unsafe medication process and the outcome for them were still to be seen. Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 21 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 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 4 3 X 3 3 X 2 Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 12 Timescale for action Care plans, risk assessments and 30/10/07 reviews must be consistent as much as possible in order for staff to easily identify assessed needs and expected action to meet these needs. These documents must be consistently dated, signed and be accurate, showing the involvement of service users in the care planning process. The weight charts kept for 30/10/07 individuals must be written in a consistent way to avoid misleading, inaccurate recording. There must be enough 30/08/07 prescribed medication for all service users at all times. Medication procedure must be 30/08/07 reviewed to prevent mistakes in administering medication to service users. Staff tasks must be reviewed to 30/08/07 ensure that medication is administered to service users without disruption to the staff member who administers medication, thus reducing risks of errors. DS0000035292.V347064.R01.S.doc Version 5.2 Page 23 Requirement 2. OP7 17, Schedule3 (3) (m) 13(2) 13(4) 3. 4. OP9 OP9 5. OP9 13(4) Welland House 6. OP27 18(1) 7. OP38 24(A) Staff must be clear of their roles 30/09/07 and responsibilities and be able to prioritise so that service users’ needs are responded to in a timely manner. An improvement plan must be 30/09/07 drawn up and demonstrate how the risks to service users would be minimised and the health and welfare of service users ensured. 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 OP7 Good Practice Recommendations Care plans should be written in appropriate language format and avoid the use of the first person in cases when the written text could be seen as undignified, offensive, or unrealistic. Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Welland House DS0000035292.V347064.R01.S.doc Version 5.2 Page 25 - 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!