Inspection on 22/06/07 for Wellburn House

This inspection was carried out on 22nd June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Wellburn House 22/11/05

Wellburn House 04/07/05

Wellburn House 14/12/04

Wellburn House 27/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Wellburn House Main Road Ovingham Northumberland NE42 6DE Lead Inspector Glynis Gaffney Unannounced Inspection 22, 25 & 29 June and 09 August 2007 2:30 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 Wellburn House DS0000000623.V330202.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. Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wellburn House Address Main Road Ovingham Northumberland NE42 6DE 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) 01661 834522 01434 636900 karenlittle@wellburncare.co.uk Wellburn Care Homes Limited Mrs M Armstrong Care Home 35 Category(ies) of Past or present alcohol dependence (1), Old registration, with number age, not falling within any other category (34) of places Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 10 elderly residents may also be suffering from dementia 22nd November 2005 Date of last inspection Brief Description of the Service: Wellburn House is a two storey detached property located in a quiet residential area on the outskirts of the village of Ovingham. The village has a local shop, two public houses and a bus service. The home has pleasant garden areas surrounding the building and many bedrooms have rural views. Wellburn House is registered to provide residential care for older people and older people with dementia. Accommodation is spread over two floors and there is a passenger lift. A further extension and improvements to the building were completed in 2006. The current charge for a place is £364 to £432. Extra charges are made for hairdressing, private chiropody services and newspapers. The most recent inspection report was available in the home’s reception area. Information about fees charged had been included in the service user guide. Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. How the inspection was carried out: Before the visit: We looked at: • • • • • Information we have received since the last visit on 22 November 2005; How the service dealt with any complaints & concerns since the last visit; Any changes to how the home is run; The manager’s view of how well they care for people; The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on the 22 June 2007. During the visit we: • • • • • • Talked with people who use the service, staff and the manager; Looked at information about the people who use the service & how well their needs are met; Looked at other records which must be kept; Checked that staff had the knowledge, skills & training to meet the needs of the people they care for; Looked around the building to make sure it was clean, safe & comfortable; Checked what improvements had been made since the last visit. We told the manager what we found. What the service does well: The home had carried out its own assessment of peoples’ needs before agreeing to offer them a place at Wellburn House. The home was: • Clean, tidy, warm, well ventilated and odour free. People said that they were very happy with the cleanliness of their bedrooms; DS0000000623.V330202.R01.S.doc Version 5.2 Page 6 Wellburn House • • Nicely furnished, well maintained and attractively decorated; Safe and free from potential hazards. The premises were set in attractive well maintained landscaped grounds. Planters and flowering baskets decorated the front of the home. There was plenty of garden furniture and a gazebo for people to sit outside in the shade. There was a range of communal areas that could be used by people wanting to socialise or have private time to themselves. Staff were kind, respectful, considerate and had developed warm and caring relationships with the people in their care. People were generally satisfied with the care and support provided. People said that the quality of meals served was good. The inspector attended the lunchtime meal and found it to be appetising, tasty and nutritious. It was nicely served by the staff on duty. There was a pleasant atmosphere at the home. were welcoming and friendly. The manager and her staff Over 90 of the staff team had obtained a relevant qualification in care. The manager and a member of the senior team had completed an extra qualification allowing them to assess and verify staff training within the home. People had access to a wide range of social activities. There was a forward planner setting out the activities to be provided each month. The home had its own transport. Staff had been invited to complete a quality survey about how the company performed as an employer. The manager had been given an extra 35 hours per week to cover shortfalls in the staff rota occurring as a result of staff sickness and holidays. What has improved since the last inspection? The home had been extensively refurbished providing accommodation and facilities. As part of the refurbishment: • • • • additional New bathroom suites had been fitted. New hoisting equipment had been provided in each bathroom; One of the day rooms had been extended and completely refurbished; New carpeting, furnishings and furniture had been provided in the majority of bedrooms; Seven new bedrooms had been created and the majority of other bedrooms had been remodelled/improved/refurbished; DS0000000623.V330202.R01.S.doc Version 5.2 Page 7 Wellburn House • • • • • • • A hair dressing facility had been provided; The kitchen and laundry had been refurbished; New equipment had been purchased such as – television sets, a fax machine, a new bar, a ‘Manga’ lifting aid, garden furniture and a gazebo, new lamp and coffee tables and other items of occasional furniture; A new fire escape had been provided; The home had been given its own transport; The car park had been re-surfaced; New flooring had been fitted in the office. 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. Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 was not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had obtained the information staff needed to provide people with a good standard of care. This meant that staff were able to fully meet the care needs of people admitted into the home. EVIDENCE: The care records of three people were examined. The manager said that people are not admitted into the home until their needs have been assessed. A Social Services assessment and care plan had been obtained in two of the care records examined. The third file was not checked for this information as the person concerned had been admitted into the home before the introduction of the National Minimum Standards. The home had carried out its own preadmission assessments before agreeing to any admissions taking place. Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 10 Qualified and experienced senior staff had carried out these assessments. The home’s pre-admission assessment proforma covered the required areas with the exception of the needs of people from different cultural and ethnic backgrounds. Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health care needs of people living at the home had been satisfactorily met enabling them to lead healthy and comfortable lives. The systems in place to support the safe administration, storage and disposal of medication were satisfactory and promoted the good health of people living at the home. EVIDENCE: The care records of three people were examined. Peoples’ care records contained useful information such as details of their level of dependency and care plans setting out how their personal hygiene and bathing needs were to be met. In one person’s care records, there were additional care plans covering the management of their catheter care needs, susceptibility to falling Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 12 and problems associated with their behaviour. The care plans were based around peoples’ strengths and their preferences for how they wanted to be cared for. The care plans were easy to understand and had been written in plain English. Staff said that they were expected to keep up to date with changes in peoples’ needs and any changes made to their care plans. Care plans covering each of the areas referred to in the National Minimum Standards had not been devised. For example, care plans covering peoples’ social care needs had not been prepared. The manager agreed to review this matter following the inspection. There was also no written evidence that peoples’ care records had been checked on a periodic basis by the manager. A key worker system was in operation and this allowed staff to work more closely with some people whilst also contributing to the care of all living at the home. Peoples’ care plans had been reviewed on a monthly basis. Each person (or their family) had signed the home’s review documentation to confirm that they agreed with the content of the care plans that had been drawn up. Comprehensive risk assessment information was available in each person’s care records. For example, risk assessments covering nutrition and susceptibility to falling had been completed. More general risk assessments had also been carried out covering areas such as bathing and smoking. The deputy manager said that pressure area care assessments would be completed where this was thought necessary. The manager said that, other than locking the front reception door to protect people at risk of wandering, no limitations had been placed on peoples’ right to make decisions and choices about how they lived their lives. The home had a medication policy that was available in the main office. All medication was stored in a locked medication trolley to which only senior staff had access. The trolley was clean, tidy and it was easy to identify what medication belonged to which person. Only limited stocks of medication were kept at the home. Photos to identify each person had been placed on the medication trolley. Lockable facilities for the safe storage of medication were available in all bedrooms. There were records covering the ordering, administration and disposal of medication within the home. All staff administering medication had received accredited training. No incidents concerning the mis-administration of medication had been reported to the Commission. Arrangements had not been made for a pharmacist to inspect the home’s medication systems and practices. Staff were aware of the need to treat people with respect and dignity when providing personal care. People said that they were happy with the way that staff cared for them. Staff were observed caring for people in a way that respected their right to privacy. Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 13 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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory arrangements were in place for providing people with opportunities to participate in a range of stimulating social activities and events. Suitable arrangements were in place to support people to maintain contact with their families and friends. EVIDENCE: There was evidence that people living at the home were able to lead full, stimulating and fulfilling lifestyles. Although social care plans were not in place in any of the records checked, staff had completed a social activities questionnaire in consultation with each person. The provision of social activities is planned in advance and a monthly list of activities is drawn up. A copy of the activity planner for June 2007 had been placed in the main Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 14 reception area. A large print copy of the programme was available. A hairdresser visited the home weekly. People were provided with access to regular religious services. Arrangements had been made for three people to access Talking Newspapers. The home also had an extensive library of large print books. The weekend following the inspection, the manager had arranged an ‘Antiques Road Show’ type event. This unique occasion proved to be very popular and successful. Staff were observed encouraging people to join in group and individual social events. For example: an exercise session led by a volunteer took place; a member of staff held a flower arranging session; one person was supported to complete a jigsaw. A local group visited the home weekly to hold a bridge session. People said that they were happy with the range of social activities provided. People spoken with confirmed that the manager and her staff always made families and friends feel welcome. People living at the home said that visitors could be seen in private or meet with their relatives in the lounges or dining areas. Nobody spoken with could recall the home placing any restrictions upon their visitors. People said that they had been supported to bring their own personal possessions with them when they moved into Wellburn House. There was a constant flow of visitors into the home and the manager and her staff were always on hand to make sure that their needs were met. A four-week rotating menu had been drawn up. Changes are made to the core menus to take account of peoples’ food likes and dislikes. Where people admitted into the home had specific dietary needs, this information had been passed onto kitchen staff. The food served at the lunchtime meal was of a good quality, well presented and met peoples’ dietary needs. Regular drinks and snacks were available throughout the day. The dining area was pleasant and the dining tables had been nicely laid out. For those individuals who needed support during mealtimes, this was carried out in a helpful and sensitive manner. Staff gave individuals the time they needed to finish their meal comfortably. People said that the meals served were usually of a good standard offering both choice and variety. People said that they received enough to eat and drink and alternatives were available to the main menu meals. Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 15 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 and 18. Quality in this outcome area is This judgement has been made using available evidence including a visit to this service. The arrangements for handling complaints were satisfactory and people were confident that their complaints or concerns would be listened to, taken seriously and acted upon. There were satisfactory arrangements to protect people from harm or abuse. This meant that people could feel safe and protected in their own home. EVIDENCE: The complaints procedure provided staff with guidance about how to handle complaints. People said that they would be happy to raise any concerns they might have with the manager or a member of the staff team. Neither the home, nor the Commission, had received any complaints since the last inspection. The safeguarding policy provided staff with guidance about how to handle adult protection concerns. There had been no safeguarding concerns raised with either the home, or the Commission, since the last inspection. Not all staff had received training in the protection of vulnerable adults. The manager addressed this shortfall during the inspection. Arrangements are now in place Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 16 to ensure that staff receive this training. People said that they felt safe and secure at the home. Staff were able to satisfactorily describe the action they would take to protect people from potential harm or abuse. Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were satisfactory arrangements to maintain, replace and improve the home’s decoration, furnishings and fittings. This meant that people were provided with comfortable accommodation that was well maintained and which satisfactorily met their needs. The home was clean and hygienic. This meant that people using the service were protected from contracting illnesses that might result in poor health. EVIDENCE: On the day of the inspection, Wellburn House was clean, safe, comfortable and Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 18 well maintained. People had access to a range of communal areas including a large lounge, a smaller lounge area, a conservatory and a dining room. All of these rooms were comfortable, nicely decorated and had a warm homely atmosphere. People had access to pleasant and attractively landscaped garden areas. The provider and manager had ensured that the home’s physical environment met the individual requirements of the people who lived there. It had a range of specialist equipment and adaptations to meet peoples’ individual needs. For example, hoisting equipment had been fitted in each bathroom as had grab rails. There was a mobile hoist. The home was fully accessible throughout to people with physical disabilities. A lift had been provided to the first floor. The entrance to the home offered level access. The home had a proactive approach to managing infection control. For example, the provider had produced an infection control policy. Anti-bacterial gel hand wash dispensers had been fitted in toilets, bathrooms, the laundry and kitchen. The home had established links with the local infection control nurse. The Department of Health Infection Control checklist had not been completed. Not all staff had completed infection control training. The manager addressed this shortfall during the inspection. The laundry was clean, tidy and well organised. The kitchen was clean, tidy and well organised. A good range of food preparation areas was available. The manager confirmed that the provider sought her opinion about decoration needed and any furnishings that might be required. She also said that each bedroom was completely redecorated before a new occupant took up residency. Mostly single room accommodation was available. Some bedrooms had an ensuite facility. There was only one double room. The bedrooms visited were clean, tidy, nicely decorated and attractively furnished. Each room had been personalised in line with the occupant’s preferences. Some of the bedrooms visited contained furniture that people had brought with them. People had been offered a key to their bedroom. Door locks were of a type that could be opened in an emergency by staff from the outside. There was a range of assisted baths available on both floors. The bathrooms were clean, tidy and pleasantly decorated. A thermometer was available in each bathroom to enable staff to test hot water temperatures. Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were sufficient staff rostered on duty to meet the needs of people living at the home. This meant that people could be sure that they would get the help and assistance they required to live as independently and comfortably as possible. There were satisfactory arrangements to ensure that staff were able to complete a relevant qualification in care. This meant that people living at the home could feel confident that staff were trained and competent to do their jobs. EVIDENCE: The staffing levels agreed with the previous registration authority were in place. During the week of the inspection, the following staffing levels were in place: • • Five staff, including the manager, between 8am and 5pm; Four staff between 5pm and 9pm; DS0000000623.V330202.R01.S.doc Version 5.2 Page 20 Wellburn House • Three night staff. The manager said that there had been odd occasions when only two staff were scheduled to cover the night shift. Staff said that there sufficient numbers of carers were rostered on duty to meet the needs of the people living at the home. The people that lived at Wellburn House also held this view. The manager is allocated 20 management hours per week to allow her to carry out her administrative and managerial duties. A sample of staff personnel records was examined and it was identified that: • • • • An application form had been completed by each member of staff; A contract of employment was available on each file as was confirmation of peoples’ physical health. Applicants had not been asked to provide a statement concerning their mental health; Staff had confirmed on their application form whether they had any convictions or cautions; A Criminal Records Bureau (CRB) Disclosure check and two written references had been obtained for each applicant. But, there was no verification of identity on any of the files examined. The manager addressed this shortfall during the inspection. The manager was advised of the need to retain CRB disclosure checks until they could be checked and signed off by the Commission at the next inspection. Staff said that they were encouraged to regularly update their statutory training. For example, all staff had completed their training in the following areas: health and safety, first aid, moving and handling and food hygiene. Some staff had not updated their moving and handling training during the previous 12 months. The manager addressed this shortfall during the course of the inspection. Over 90 of the staff team had obtained a national recognised qualification in care. Some senior staff had obtained an Assessors qualification. The manager had devised a chart that allowed her to maintain an overview of which staff required what training and when. Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 36 and 38. Quality in this outcome area is This judgement has been made using available evidence including a visit to this service. There were suitable arrangements for keeping peoples’ money and valuables safe. This meant that people living at Wellburn House could be sure that their money and financial interests were being safeguarded. There was a satisfactory programme of regular and structured staff supervision. This meant that staff were properly supervised, received support and guidance in meeting the needs of people living at the home, and had their performance regularly appraised. Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager had obtained a relevant qualification in management. She had extensive experience of working in a residential setting for older people and displayed the professional competence required to manage such a home. The manager was ably supported by an experienced senior management team. The manager had not obtained a relevant qualification in care at level 4. Mrs Armstrong and her team worked very hard to improve the lives of the people living at the home. Staff felt that the manager’s style of leadership was fair, supportive and understanding. Staff also said they were clear about the standards of care which they were expected to achieve. The majority of people living at Wellburn House had requested that the home take on day-to-day responsibility for overseeing their money. Each person had their own separate wallet in which their money was kept. A safe place was available to ensure that their money could be kept secure. Staff signatures had been obtained for all money spent on behalf of people living and receipts had been obtained. Financial records showed evidence of regular audits. Internal systems had been developed to monitor the quality of care provided in the home. For example, quality surveys had been sent to people and their relatives. Staff had also recently been surveyed. The manager said that surveys had not been sent to relevant professionals visiting the home. Visits to monitor the quality of care provided at the home had been carried out on behalf of the provider. All staff working at the home had received supervision at least six times during the last 12 months. Records had been kept of the supervision sessions held. Each member of staff had received an appraisal within the last 12 months. A range of health and safety records was in place. The home had a health and safety policy. A tour of the premises identified no health and safety concerns. An audit of the home’s fire records confirmed that the required fire prevention checks had been completed. An up to date fire risk assessment was in place. A record of all accidents occurring within the home had been kept. There was a gas safety certificate and all electrical appliances had been tested. A range of workplace risk assessments had been completed. Checks to prevent the spread of Legionella, such as disinfecting shower heads and testing water temperatures, had been carried out. The manager said that the home’s water systems had not been checked for the actual presence of Legionella. Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 x X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 X 3 3 X 3 Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 24 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 15 Timescale for action Ensure that peoples’ care plans 01/12/07 cover each of the areas referred to in the National Minimum Standards. Where ongoing assessments indicate that a care plan is not required in a particular area, a written record should be kept to evidence the home’s decision making processes. Ensure that all staff have 01/01/08 received training in safeguarding vulnerable adults. The manager must obtain relevant qualification in care. a 01/01/09 Requirement 2. OP16 13(6) 3. OP31 9 Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 25 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 YA7 Good Practice Recommendations The manager should carry out periodic inspections of peoples’ care records to ensure consistency of information and quality of recording. A written record should be kept. Assess each person’s susceptibility to developing pressure area needs. Keep a written record. Arrange for a pharmacist to inspect the home’s medication systems, policies and procedures. Complete the Department of Health Infection Control checklist. Obtain the views of relevant professionals regarding the conduct of the home and the quality of the service. Regularly check the home’s water system for the actual presence of Legionella. 2. 3. 4. 5. 6. OP8 OP9 OP26 OP33 OP38 Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Wellburn House DS0000000623.V330202.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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