Inspection on 14/11/07 for Wellfield House

This inspection was carried out on 14th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wellfield House 05/05/09

Wellfield House 25/03/09

Wellfield House 15/01/09

Wellfield House 10/04/08

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Wellfield House Manor Road Catcott Bridgwater Somerset TA7 9HT Lead Inspector Jane Poole Unannounced Inspection 14th November 2007 09:30 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 Wellfield House DS0000065827.V353293.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. Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wellfield House Address Manor Road Catcott Bridgwater Somerset TA7 9HT 01278 722405 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) Farrington Care Homes Ltd Mrs Susan Margaret Pear Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2006 Brief Description of the Service: Wellfield House is an attractive property located in the centre of Catcott village, approximately eight miles from Street and Bridgwater. The premises have been registered as a care home since 1989 and provide accommodation on two floors. There is parking for four to five cars at the front of the building. The home has a cottage annexe built in the grounds which houses a further three bedrooms. Wellfield House is registered with the Commission for Social Care Inspection to provide personal care for 21 people over 65 years of age. The home does not provide nursing care although district nurses visit the home regularly to provide treatment and advice. The home provides day care for up to two people six days a week. Farrington Care Homes Limited purchased the home in 2005. The responsible individual is Mr Kiran Nathwani. The manager Mrs Susan Pear has had many years experience of working with older people and managing care staff. There continues to be a strong commitment by the small team of established carers and support staff providing a good standard of care in a relaxed family style home. Fees at the home range from £378.00 to £458.00 per week. Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. The inspector spent the day at Wellfield House and during this time was able to speak with service users and staff, observe care practices and view the premises. The manager was at the home throughout the day and all records requested were made available. Prior to the inspection the manager completed an Annual Quality Assurance Assessment (AQAA) setting out the homes achievements over the past year and their plans for the future. 4 service users and 3 relatives/carers completed questionnaires prior to the inspection and some comments have been included in this report. What the service does well: What has improved since the last inspection? Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 6 Since the last inspection the home has implemented a new, more comprehensive, care plan system. A maintenance person has been employed to ensure that all areas are maintained to a high standard. The kitchen has been replaced and some rooms have been redecorated. What they could do better: There are two outstanding requirements from the last inspection. Staff have still not received up dated training in first aid although the date for compliance with this was the 16th October 2006. The recruitment procedures in the home continue to be poor and do not minimise the risks of abuse to service users. Service users spoken to were generally happy with the service provided. When asked what could be improved many said that they could not think of anything. Some people said there would like there to be more activities in the home and one person wanted more trips out. One service user said that a greater variety of food would be good. There is limited information in care plans about peoples hobbies and interests. The home need to consult with service users about this to ensure that everyone receives appropriate social stimulation and the opportunity to take part in activities in line with their interests. There are very limited records in respect of staff training and it is therefore difficult to ascertain which staff have received appropriate, up to date, training. Although staff spoken to were not unhappy with the level of training available, there is no evidence that all staff have received fire safety training and the induction programme needs to be made more comprehensive in line with the ‘skills for care’ 12 week programme. The company are introducing training videos and the home must keep clear records of these. The home needs to ensure that the fire detection system, including emergency lighting, is regularly tested and serviced. In addition to the main house there is a small annexe, which has three bedrooms for service users. There is a small communal room in the annexe which would benefit from being made more homely to offer service users an alternative seating area away from their bedroom. Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 7 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. Wellfield House DS0000065827.V353293.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 Wellfield House DS0000065827.V353293.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): 1, 3 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users receive adequate information about the home before they move in. Prospective service users have opportunities to spend time in the home and stay for a trial period before deciding to move in on a permanent basis. Intermediate care is not provided. EVIDENCE: There have been no changes to the statement of purpose or the service user guide since the last inspection. Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 10 The manager obtains copies of assessments completed by professionals outside the home before offering a place to new service users. Copies of these assessments were seen in service users personal files. Prospective service users and/or their representatives are encouraged to visit the home before deciding to move in to ensure that it meets their expectations. The manager stated that if someone living at the home has a stay in hospital then she reassesses them before they return to Wellfield House to ensure that the home remains suitable. Service users spoken to during the inspection stated that they or a family member had spent time in the home before taking up residency. One person stated that they had had a respite stay before deciding to move in on a permanent basis. All 4 service users who completed a questionnaire prior to the inspection answered YES to the question “ Did you receive enough information about the home before you moved in?” The inspector saw a copy of a signed contract, which clearly stated that the first four weeks of any stay is a trial period. Wellfield House DS0000065827.V353293.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 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A new, more comprehensive, care plan system has been introduced and the home need to ensure that these are kept up to date and reflect the current needs and wishes of the service user. The majority of people asked felt that staff treated them with respect. EVIDENCE: Since the last inspection the home has introduced a new care plan system. The inspector viewed the care plans of three service users. The quality of the care plans was variable. One was very comprehensive and gave clear information. One, although it had been recently reviewed, did not contain up to date information about the person. There was no evidence that all care plans were created and reviewed in consultation with service users. All medical appointments are recorded and daily records are written about each person and again the quality of these was variable. Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 12 Service users have access to GP’s, district nurses, chiropodists, an optician and other healthcare professionals according to their individual needs. 2 service users answered ALWAYS and 2 answered SOMETIMES to the question “Do you receive the medical support you need?” The 3 relatives/carers who completed questionnaires answered USUALLY to the question “Does the home give the care and support that you expect or agreed?” The manager stated that the home had good relationships with local healthcare professionals. If people need to attend appointments outside the home then families are asked to assist, if this is not possible then the home arranges transport and support. Medication is supplied by the surgery and is dispensed from the original packaging. There is appropriate lockable storage within the office and each person has a separate box for their medication. When medication is administered the boxes are placed on an open trolley and taken to a communal area. The home should risk assess this practice and take appropriate action to ensure that it is safe. All Medication Administration Records (MARs) are handwritten and each entry is signed. The record is then checked by the manager before it is put into use. MARs seen were correctly signed when administered or refused. The inspector observed that staff interacted with service users in a friendly polite manner. Most people spoken to said that staff were respectful but two people said that staff were not always polite. This was discussed with the manager who will look into this. Service users are able to spend time in communal areas or the privacy of their rooms. Wellfield House DS0000065827.V353293.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 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some activities are arranged in the home and service users are encouraged to maintain contact with friends and families. Routines in the home are flexible in line with the wishes and choices of service users. Service users are happy with the food provided in the home. EVIDENCE: Service users stated that routines in the home were flexible and they were free to choose what time they got up, when they went to bed and how they spent their day. Care plans seen had basic life histories but did not fully record peoples interests and hobbies in all instances. There are some organised activities in the home. People said that they had an exercise class on a regular basis and there were often quizzes and games that they could take part in. On the day of the inspection there was a church Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 14 service in the morning that was well attended and some people had their hair done by the visiting hairdresser. Some people said they thought that the home would benefit from more activities and one person said that it would be nice if staff had time to sit and chat. The home has purchased a new large screen TV for the lounge. The inspector noticed that this was put on in the lounge after lunch without any consultation with service users using the room. One person stated that they went out to a nearby town on the bus and others said that they frequently went out with friends and family. Everyone said that visitors are always welcome in the home and that they are able to see people in communal areas or in their private rooms. 2 service users who completed questionnaires answered USUALLY and 2 answered SOMETIMES to the question “Are there activities that you can take part in?” One person commented that they would like more trips out. The manager stated that they had reduced the number of outings due to the frailty of many service users and were trying to have more in house entertainment and activities. The main meal of the day is at lunchtime, there is a four-week menu but this is varied according to what is available. There is currently only one choice of main meal although service users stated that they are able to ask for an alternative if they wish. The home would benefit from displaying an alternative on the menu to enable service users to make a choice rather than have to ask for an alternative. The inspector was invited to join service users for lunch. The food was well cooked and presented, the atmosphere was relaxed and unhurried. Some people enjoyed a glass of sherry with their meal. Everyone spoken to was happy with the quality of the food in the home. Wellfield House DS0000065827.V353293.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 & 18. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users know how to make a complaint and are confident that any concerns raised would be listened to. The recruitment practices in the home are not robust and do not protect service users from abuse. EVIDENCE: The home has policies and procedures in respect of making a complaint, recognising and reporting abuse and whistle blowing. The whistle blowing policy needs to be up dated to give contact details of the Commission for Social Care Inspection, this was raised at the last inspection. Since the last inspection one complaint has been made to the home and this is recorded in the complaints log along with action taken. All 4 service users who completed questionnaires answered YES to the question “Do you know how to make a complaint?” Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 16 Service users spoken to stated that they would be comfortable to approach a member of staff if there was any aspect of their care that they were unhappy with. All asked were confident that they would be listened to. The manager carries out some training with staff about aspects of abuse however this training is not currently recorded in the homes training records. Some staff spoken to stated that they had undertaken training in the protection of vulnerable adults as part of their National Vocational Qualification. Service users were seen to move freely around the home and had unrestricted access to all communal areas and their personal rooms. The inspector viewed the recruitment records of three recently employed members of staff. In one case the check against the Protection Of Vulnerable Adults (POVA) register had not been received back until two days after they began work in the home and written references were not received until some time after their employment commenced. Another person had started work in the home before written references were received. And the third person had no application form and only one recorded telephone references. Criminal Records Bureau (CRB) checks were in place for all three staff by the time of this inspection. The issues of staff recruitment have been raised on previous inspections. Wellfield House DS0000065827.V353293.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, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Wellfield House offers a comfortable homely environment for service users. Service users are able to personalise their bedrooms to give them an individual feel. EVIDENCE: The home is located in the small village of Catcott. It is an attractive building in keeping with other village properties. Service user accommodation is located over two floors with a stair-lift between. In addition to the main house there is an annexe, which is able to accommodate three service users. Service users stated that there are two pubs in the village that it is on a public transport route. Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 18 All areas of the home are fitted with a fire detection and call bell system. All communal areas are located on the ground floor. In the main house there is a large lounge/diner that is light and spacious and a smaller quiet lounge that can be used by service users and visitors. In the annexe there is a small lounge area that would benefit from being made more homely to offer another comfortable alternative seating area for service users. Outside there is a very attractive garden that many service users stated that they enjoyed spending time in. Since the last inspection the home has replaced the kitchen. At the time of the inspection all bedrooms were being used for single occupancy. Rooms seen by the inspector had been personalised in line with the tastes and needs of the service user. All were clean and had a homely feel. 19 bedrooms have en suite facilities. The laundry is located in the main house and has a commercial washing machine and drier that are appropriate to the needs of the service users. Currently there are no suitable hand-washing facilities for staff in the laundry. Wellfield House DS0000065827.V353293.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 & 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels in the home are adequate to meet the physical needs of the current service user group. The recruitment procedures are not robust and do not fully protect service users. There is no written evidence that staff are receiving appropriate ongoing training to carry out their roles. EVIDENCE: The home employs 15 care staff, 8 have a National Vocational Qualification (NVQ) at level 2 or above. Since the last inspection the home have reviewed the staffing levels in the home and made an additional 3 hours available each morning. The manager stated that the additional hours have been used to increase the staff in the kitchen first thing in the morning to ensure that care staff are able to assist people with personal care and the kitchen are able to ensure that everyone has breakfast and the support that they need in the dining room. Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 20 Care staff are also responsible for organising and facilitating activities and social stimulation. Staff spoken to felt that the home was adequately staffed. Rotas given to the inspector showed that there are 2 care staff on duty each morning and 2 in the afternoon. The managers’ hours and all ancillary hours are in addition to this. Overnight there are two care staff on duty. Staff are based in the main house and regularly go to the annexe both during the day and the night. In response to the questionnaire question “Are staff available when you need them?” 1 person answered ALWAYS and 3 answered USUALLY. The inspector spoke with one person who had been employed since the last inspection. They felt that they had received a good induction and were well supported when they began work at the home. The home has their own short induction programme where the new member of staff works alongside the manager. The inspector did not see records in respect of this training. Staff felt that there were generally good opportunities for training and felt that they could approach the manager if they wished to undertake any courses. Training records showed that staff had received training in manual handling in May of this year but no further training was recorded. A requirement was made at the last inspection for staff to receive first aid training and this has not yet been complied with. Some staff have not received training in fire safety within the last twelve months, although some have taken part in practice fire drills. All 3 relatives/carers who completed questionnaires answered USUALLY to the question “Do staff have the right skills and experience to look after people properly?” One member of staff said that team meetings are used to provide up dates on training issues but these are not recorded on personal training files. The company are planning to implement training videos that can be used with all staff. The inspector viewed the recruitment records of three recently employed members of staff. In one case the check against the Protection Of Vulnerable Adults (POVA) register had not been received back until two days after they began work in the home and written references were not received until some time after their employment commenced. Another person had started work in the home before written references were received. And the third person had no application form and only one recorded telephone references. Criminal Records Bureau (CRB) checks were in place for all three staff by the time of this inspection. Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 21 The issues of staff recruitment have been raised on previous inspections. Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 22 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, 33, 35 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager has the qualifications and experience to manage the home. Staff would benefit from training in health and safety issues such as first aid and fire safety to ensure that their practice is up to date and promotes safe working practices. EVIDENCE: The registered manager of the home is Sue Pear. She has many years experience of working with older people and demonstrates a good knowledge Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 23 of the service users living at the home. She has completed the Registered Managers Award (NVQ level 4.) The home is owned by Farrington Care Homes Ltd and the manager stated that she is well supported by the company. When the manager is not at the home there are 3 care supervisors who run the home with on call back up from the manager. Service users said that the manager was very visible in the home and it was observed that service users and staff were very comfortable with her. Sue works alongside care staff to offer ongoing support and guidance to less experienced members of staff. The company send out regular quality assurance questionnaires to gauge the level of satisfaction with the service. The area manager explained that the most recent survey is currently being analysed and the final results will be forwarded to the homes manager shortly. The home does not act as a financial appointee or power of attorney for any person living at the home. Small amounts of money are kept on behalf of some service users, records sampled by the inspector showed that appropriate records are maintained. Records kept correlated with monies held. Some requirements in respect of health and safety were made at the last inspection. It was required that all freestanding wardrobes be secured to avoid the risk of them falling forward and causing injury to a service user. The manager gave assurances that this work had been carried out. It was also required that all staff receive up dated first aid training. This requirement has not yet been complied with. The fire log was viewed by the inspector. The alarms are tested in house on a weekly basis. The emergency lighting is tested 6 monthly. There are no clear records to demonstrate that all staff are receiving regular training in fire safety although the home have conducted fire drills that some staff have taken part in. There was no evidence in the home that the fire detection system had been serviced. (The inspector spoke with the manager the following day and assurances were given that a contract had now been set up to service the fire detection system regularly.) Portable electrical appliances were last tested in September of last year and are now due for re testing. The stair-lifts were serviced in September ’07 and other lifting equipment in October ’07. (Dates taken from Annual Quality Assurance Assessment completed by the home) Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 24 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 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 3 x x x 3 x 2 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 1 Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 OP29 OP18 Regulation 19 (1) (b) (i). Requirement It is required that the manager ensures that all staff employed at the home have information in accordance with Schedule 2 of the Care Standards Act on their recruitment file. This is carried forward from the last inspection. Recruitment practices must be robust and minimise the risks of abuse to service users. It is required that the manager arranges First Aid update training for staff. This is carried forward from the last inspection. Timescale for action 20/11/07 2 OP38 13 (4) 31/01/08 3 OP7 15(2) 4 OP9 13 (2) 5 OP10 12(4) [a] Care plans must be drawn up in 31/01/08 consultation with service users where appropriate. All care plans must be kept up to date to ensure that they give clear guidance for staff. The home must carry out a risk 15/12/07 assessment in respect of the use of an open trolley for medication. Action must be taken to address any risks identified. The manager must ensure that 14/11/07 DS0000065827.V353293.R01.S.doc Version 5.2 Page 26 Wellfield House 6 OP12 16(2) [m][n] 7 8 OP26 OP30 13 (3) 18 (1)[c] 19 (1)bSch 2 23 (4) [c(iv)][d] 9 OP38 service users are treated with respect at all times. The manager must ensure that service users are consulted about their social interests and provide appropriate activities and social stimulation for all. The manager must ensure that there are suitable hand-washing facilities for staff in the laundry. The manager must ensure that all staff receive training appropriate to work that they do and records are kept of training undertaken. The manager must ensure that all staff receive regular training in fire safety. The fire detection equipment in the home must be regularly serviced. 28/02/08 31/12/07 28/02/08 30/11/07 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 OP18 Good Practice Recommendations The manager should ensure the Abuse and Whistleblowing policy make clear that informants are able to contact Local Authority Social Services and Commission for Social Care Inspection. Recommendation made at previous inspection. The manager should ensure that alternative meals are written on the menu to enable service users to make a choice about the food they eat. The manager should ensure that the lounge in the annexe provides a comfortable environment for service users and their visitors. The manager should ensure that all staff undertake an induction programme in line with the ‘skills for care’ 12 week programme. DS0000065827.V353293.R01.S.doc Version 5.2 Page 27 2 3 4 OP15 OP20 OP30 Wellfield House 5 OP38 The manager should ensure that: • Emergency lighting is tested on a monthly basis. • Portable electrical appliances are tested annually. • The electrical installation is tested regularly. Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Wellfield House DS0000065827.V353293.R01.S.doc Version 5.2 Page 29 - 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!