Inspection on 20/04/06 for Wells Road Care Home

This inspection was carried out on 20th April 2006.

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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wells Road Care Home 15/02/09

Wells Road Care Home 19/03/08

Wells Road Care Home 05/09/07

Wells Road Care Home 11/04/07

Wells Road Care Home 15/02/06

Wells Road Care Home 21/03/05

Wells Road Care Home 29/03/04

Wells Road Care Home 10/11/03

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Wells Road Care Home 280-282 Wells Road St Anns Nottingham NG3 3AA Lead Inspector Joanna Carrington Unannounced Inspection 20th April 2006 10:00 Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 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 Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Wells Road Care Home Address 280-282 Wells Road St Anns Nottingham NG3 3AA 0115 955 5162 0115 950 2066 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) Nottingham Community Housing Association Mrs Karen Allison Martin Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users shall be within category LD Date of last inspection 15/02/06 Brief Description of the Service: Wells Road Care Home is situated in the residential area of St Anns, close to shops and amenities and is registered to provide accommodation and support for up to six adults with a learning disability. The home itself is comprised of a pair of semi-detached houses joined together and the accommodation consists of communal lounge, dining room and kitchen on the ground floor and six single bedrooms with shared bathing facilities on the upper floor. There is currently one vacancy. The home has enclosed front and rear gardens accessible to residents. The manager of the home, Carmel Hopkinson is currently in the process of registering as manager with the Commission. The home is currently run as a partnership with Nottinghamshire Healthcare Trust who provide the staff. This is due to change with the Healthcare Trust pulling out and Nottingham Community Housing Association taking on their employment. This is due to take place in July 2006. The set fees at the time of this inspection are £348 per week. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over seven hours on 20th April 2006. This was the home’s key inspection for this inspection / financial year. The main method of inspection was called ‘case tracking’ which meant selecting three residents and tracking the support they receive through checking their records, observation of care practice and discussion with staff. Due to the limited communication of the residents living at the home the inspector did in brief speak with two of the three residents case tracked. Staff records were looked at and a partial tour of the premises also took place in order to assess environmental standards. As no other information and evidence had been gathered prior to the inspection all of the key standards were assessed during the inspection. Two staff members were spoken with and the manager was available for discussion and feedback throughout. What the service does well: Individuals’ risk assessments are done well as these are not only used for protecting residents but also to identify ways that residents can participate in their chosen activities safely and promote their independence. Staff are fully aware of the communication needs of individual residents and there are excellent tools currently being implemented to aid communication and enable residents to be more involved in the running of the home. There is advocacy involvement for residents that do not have their own families, which is important for ensuring that support given is in their best interest. Residents rights are respected and staff enable residents to maintain contact with family and friends. A range of fulfilling and community-based activities is provided and it is apparent that staff are committed to promoting the quality of life and individuality of residents. Residents’ have good access to healthcare services and professionals and personal support is given to residents in a way that is preferred and required. The support plans seen demonstrated that the individual preferences of residents are accommodated such as with appearance and bathing routines. Staff are aware of their responsibilities in accordance with the local Nottinghamshire Adult Protection Procedures, which is important for safeguarding residents from abuse. There is an appropriate complaints procedure, to ensure that any concerns or complaints of residents are appropriately responded to and taken seriously. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 6 The home is clean and hygienic. Staff are well supported and have good training opportunities, which ultimately residents benefit from as this helps to ensure that the needs of residents are met. What has improved since the last inspection? 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. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality for this outcome area is adequate. Prospective service users needs are assessed before they move to the home. EVIDENCE: For all three residents’ case tracked the placing authority’s community care assessment was available, which would have informed the development of individuals’ support plans. At previous inspections it was noted that the assessment obtained for one resident was not as up to date as it should have been therefore did not provide adequate information. The requirement to ensure that this residents needs are fully assessed is still within timescale and the manager was able to provide evidence that there has been contact with the social work team in order for Social Services and the staff team to do a joint assessment of this individuals’ needs. The requirement remains in this report with the timescale set at the previous inspection. This is therefore not identified as outstanding. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality for this outcome area is good. Residents assessed needs are reflected in their respective support plans and there is significant improvement with reviewing, which ensures that changing or increased needs are identified and met. Staff are committed to enabling residents to exercise choices and make decisions in their lives. Residents are supported to take acceptable risks in order to promote their independence and quality of life. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 10 EVIDENCE: For all three residents case tracked there was clear evidence on their support plans that these are regularly reviewed to ensure that the plans are still relevant or if they need changing. This is big improvement since the last inspection when copies of support plans held on files were from as far back as 2004 therefore this requirement has now been met. When staff were asked about how support is given to certain individual their support plans reflected very accurately what staff said. Support plans cover all aspects of personal and social support healthcare and emotional / behavioural needs. For one resident a requirement was set at the last inspection for support plans to be devised in respect of their memory loss and behaviour. The deadline for compliance has not been reached yet. The requirement remains in the report however it is acknowledged that further information is now available on this individual’s support plan which provides the necessary guidance to staff, which minimises any incidents of aggressive behaviour. The accompanying risk assessments are very good, identifying when there are restrictions imposed on an individuals’ freedom. For example, due to poor road safety skills a resident may have to always be accompanied when they go out. There are risk assessments in place specific to individuals’ interests and chosen activities and for different elements of daily living. Staff spoken with demonstrated a good understanding into the communication needs of residents, which are documented in a relevant support plan. Staff gave good examples of ways to communicate with individuals such as using objects of reference and pictures. One staff member showed the inspector the work that is currently being undertaken in developing a pictures and symbols system using notice boards. Residents have been involved in doing pictures and setting this up. This is to be commended. There is advocacy involvement for residents that do not have family. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality for this outcome area is good. Residents’ rights are respected and upheld including the right to have and maintain appropriate family and personal relationships and there are opportunities for residents to participate in fulfilling, appropriate and community-based activities. Residents are involved in menu planning but if menu records are not filled in properly it cannot be determined whether an adequate diet is being offered to residents. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 12 EVIDENCE: Staff spoken with recognise the importance of upholding residents’ right to privacy and dignity. Staff were observed interacting with residents in a respectful and meaningful manner. Where relevant, support plans highlight the importance of maintaining dignity. As the residents that live at this home are not able to use a key to their own bedrooms this should actually be recorded on relevant support plan / risk assessment in order to fully acknowledge their right to privacy and security, and how this can be best achieved. A resident has a sound monitor in his bedroom which is used at night. A support plan must make reference to the use of this monitor and in order to fully respect his privacy it must highlight when this monitor is only to be used. Staff demonstrated a strong sense of commitment to providing activities, access to the community and ultimately promoting peoples quality of life. During the inspection staff were observed playing board games with residents and also helping in developmental and learning activities. Each resident has a ‘social chart’ for recording when and what activities have been participated in. These range from outings to the pub, day trips, shopping, going out in the mini bus or for walks. Last week two residents went to Alton Towers and next week two residents are going to Skegness for the day. There are relevant support plans indicating ways that staff support residents to maintain contact with their family for example, with using the phone and taking residents to visit. Some residents have regular weekends away with family. A resident is currently being supported with the involvement of their social worker and advocate in a growing personal relationship. The manager explained that for the named resident referred to in the previous report they had decided themselves to retire from day services then went back just for two days per week to be involved in gardening and woodwork which is what they are interested in. Staff spoken with stated how for this resident a routine is now emerging, encouraging them to go out more during their days they are not at the day centre which is having a positive impact in other ways. This was reflected in a relevant support plan. Therefore, the requirement to allocate more structured day care no longer applies, as long as the resident’s wishes are being met. Overall access to day services and other provision is good for residents, with activities matched to suit their needs and interests. One resident goes to music therapy every week. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 13 Two residents were observed being involved in the menu board and shopping. There is a system in which a different resident each week chooses the weekend’s ‘healthy meal option’ then they help prepare it. This is good practice. There were an unacceptable number of times when the menu book has not been filled in by staff and some entries are not detailed enough to show variety, for example what vegetables have been provided and how potatoes have been served. Making detailed records is set as a requirement. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality for this outcome area is good. Residents receive personal support in the way they prefer and require and their physical and emotional healthcare needs are well addressed. Some errors were found with the medication system, which means that current procedures are not at a safe standard. EVIDENCE: Appointment records were seen for residents indicating that there is good access to GPs and district nurses when necessary and also to other special healthcare professionals such as psychiatrists and learning disability nurses, to assist in meeting the emotional and physical health needs of residents. Staff spoken with identified the preferences of certain residents with how their personal support is given such as with their appearance and bathing routines and this was reflected in the respective support plans. A resident with increasing mobility difficulties has had input from an occupational therapist for the provision of necessary aids and adaptations to help mobilise around the home as independently and safely as possible. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 15 Medication administration records (MAR) were audited for the three residents case tracked and there were some errors identified. A pre-dispensed cassette system is used along with typed MAR sheets. The home does not get to see the prescription from the GP as this goes straight to the pharmacy. The problem with this system is that the home cannot audit trail to make sure that the medicines dispensed and instructions on the MAR correlate with the prescription from the GP. For one resident a dose of liquid medicine was not signed for. For another resident there is medication specified on a handwritten Nottingham Community Housing Association MAR but the quantity has not been signed in. The main concern, however is that this medication is also on the typed MAR, not crossed out. This is not safe practice. For another medication instructions on the box and on the MAR state to be taken in the evening but it is being administered in the morning. The manager explained the reason for this and that the psychiatrist was consulted before making this change. There must be a record of this with the MAR as evidence. The start date for this medicine is wrong and although the correct number of tablets has been administered there is a gap on the MAR where one has not been signed for. For another medicine this is being given once a day even though the box and MAR instructs twice per day. Instructions from the psychiatrist on this residents file states once per day. This needs to be followed up as a matter of urgency to ensure that instructions and medication is being administered correctly. All the preceding information explains why it is recommended that the home keep photocopies of scripts to be kept with MARs. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality for this outcome area is good. There is an appropriate complaints procedure in place and staff are aware of the Nottinghamshire Adult Protection Policy and Procedures and of their responsibilities in protecting residents from abuse. EVIDENCE: There is an appropriate complaints procedure, which is also in a Signs and Symbols format. There have been no complaints made either by residents or their relatives / representatives in the last year. A resident has very recently made an allegation against a member of staff. This has so far only been notified during the inspection. A written notification to the Commission is still required. So far the necessary action has been taken. A notification to the Adult Protection Unit is being made and Social Services are in the process of being informed, in order to identify the Investigating Co-ordinator and the investigation will proceed. Staff spoken with demonstrated an awareness of the Nottinghamshire Adult Protection Policy and Procedures and an understanding of their responsibilities in respect of disclosing allegations and whistleblowing. The manager must ensure that any investigation records made in relation to this allegation are held securely on the staff member’s file. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality for this outcome area is adequate. The environment overall has a homely domestic feel however improvements to décor in parts of the home is required. The home is clean and hygienic. EVIDENCE: There is now lovely new leather furniture in the lounge and with lots of pictures and photos displayed there is a personal and homely feel in the lounge / dining area of the home. On a tour of the premises it became apparent that there are areas of the home, which are in need of redecorating. There is paint crumbling off walls in some bedrooms and communal parts of the home. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 18 One resident’s bedroom is particularly sparse, with very little items and furniture with Perspex attached to walls. This room is also in desperate need of redecorating. Although it is appreciated that this room is the way it is given the complex needs of the individual there is no support plan indicating why this room is so empty and why it does not have the acceptable amount of furniture that should be provided. This is required. The home appeared clean and hygienic throughout. There is a daily jobs and cleaning rota for staff, which is helpful in ensuring all necessary cleaning tasks are undertaken. The laundry facilities are appropriate to the needs of residents and some residents, with support, wash their own laundry. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality for this outcome area is adequate. The staffing levels and general training and support of staff helps to ensure that the needs of residents are met however improvements to recruitment practice are required for the protection of residents. EVIDENCE: The staff rota shows that staffing levels never go below an acceptable minimum and at times a greater number of staff are on so that activities and community access can be facilitated. Sometimes agency staff have to be utilised but staff spoken with said that this is not a problem because the same agency workers are used to provide stability and familiarity for the residents. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 20 Staff spoken with reported that they receive good levels of training. This includes all the necessary mandatory training such as Food Hygiene, First Aid and Adult Protection as well as training more specific to the needs of residents such as autism awareness, de-escalation techniques and epilepsy. Nottingham Community Housing Association will have to pick up where the Healthcare Trust have left off, when the staff transfer finally goes through, as National Vocational Qualification (NVQ) Level 2 training is currently on hold. The target of 50 of the staff team to be qualified to at least NVQ Level 2 has not yet been achieved. This is now made a requirement. Staff records show that supervision sessions are undertaken with staff, and those team members spoken with confirmed that their support is very good. Three staff files were examined during the inspection. Two of these files contained two written references while the other file contained no references. Each file contained a letter from the Healthcare Trust confirming that the Criminal Record Bureau disclosure has been received. However, this letter is dated at least a month after each staff member has commenced their employment and does not include the date when the CRB was actually issued. There is no evidence that a POVA First Check has been carried out, which is the only way staff can commence their employment before a full CRB has been returned. Due to ongoing problems with staff files at Nottingham Community Housing Association care homes, an additional unannounced visit was made in March 2006 to the Nottinghamshire Healthcare Trust to inspect the centrally held files. For Wells Road care home the manager’s file and two randomly selected staff files were looked at. One of the staff files appeared to only contain one reference. For the manager there is no evidence of further references being obtained following their application as manager. It was not clear on any of the files when staff commenced employment at Wells Road. There was no evidence of CRB checks. After this visit NCHA informed the Commission that the staff files looked at were in fact not the full files, as these are held at another site, which they were unaware of. Therefore, the correct staff files were not made available at the time of inspection. A requirement has been made in respect of recruitment checks and it is expected that NCHA will fully address this requirement when the staff transfers take place. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality for this outcome area is adequate. Fire safety practice has improved which is important for the health, safety and welfare of residents. Improvements to quality monitoring are still required to ensure the home is run in the best interests of service users. EVIDENCE: All staff spoken with were very positive about the efforts of the manager, and their supportive and inclusive approach. The manager has now submitted their full application to the Commission for registration, which is currently being processed. It was evident during the inspection that requirements made in previous inspections have been responded to and addressed. The manager is currently doing their NVQ level 4 registered managers award. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 22 Monthly, unannounced visits by the registered provider are still not taking place. A pro forma has now been implemented for this task but until the monthly visits commence it remains as a requirement in this report. Although there are good internal policies and procedures for quality assurance, this is not being put into practice. The last quarterly quality audit for the home was undertaken almost a year ago and no work has been done to obtain the views of residents, their relatives / representatives and stakeholders. This is required. Unlike at the last inspection, this time the fire log showed that all necessary fire safety tests and practices are being carried out in accordance with Fire Precautions in the Workplace legislation. All staff have received up to date fire awareness training however the very poor outcome of a recent fire drill indicates more work is required with staff. It is recommended that more frequent fire drills are carried out, as an added precautionary measure and ultimately for the safety and protection of residents and staff. Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 1 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 1 X X 3 x Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 24 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 Requirement For the named resident ensure that there is a full assessment of their needs, which then informs their care plan. This requirement is repeated from the previous inspection but not identified as outstanding because timescale for action has not yet passed. Please supply evidence once completed Develop support plans (following full assessment of need of the named resident, see above) with particular attention to behaviour and memory loss). This requirement is repeated from the previous inspection but not identified as outstanding because timescale for action has not yet passed. Please supply evidence once completed. In accordance with Schedule 4 Care Home Regulations 2001 ensure that there is a record of the food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory. Ensure there are adequate DS0000002259.V288233.R01.S.doc Timescale for action 30/04/06 2. YA6 15 30/04/06 3. YA17 17(1) 14/05/06 4. YA20 13(2) 30/04/06 Page 25 Wells Road Care Home Version 5.1 5. 6. YA24 YA32 23(2)(d) 18 7. YA39 24 and 26 arrangements in place for the storage, recording and administration of medicines. This includes… 1. Ensure administration reflects what is stated on the MAR and when instructions have changed these are amended on MAR attaching evidence that appropriate medical person has implemented this change. 2. Ensure staff follow procedures in place if a missed dose / gap on MAR is identified. 3. Recording the quantity of boxed medication on handwritten MAR charts. 4. Retain a copy of prescription with MAR for purposes of audit trail and ensuring residents are being administered medicines as instructed by the GP. 5. Monitor the temperature of the medicine cabinet to ensure safe storage. Ensure all parts of the home are kept reasonably decorated and a good state of repair internally. Ensure a minimum of 50 of all staff are qualified to at least National Vocational Level 2 Social Care. As part of quality assurance, ensure monthly, unannounced visits are carried out then supply report to the Commission. Maintain system for reviewing at appropriate intervals and improving the quality of care. The system shall provide for consultation with service users and their representatives. 31/08/06 31/10/06 30/07/06 Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 26 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 YA16 Good Practice Recommendations Add to the relevant support plan / risk assessment individuals’ ability to use a key to their bedroom and if support is appropriate in enabling a resident to use a key, or if other measures are in place to promote their right to privacy and security etc. Refer to the use of a sound monitor in the relevant risk assessment and when this is only to be used. Record why the named resident does not have the required items of furniture as specified in the National Minimum Standards. Record why the named resident does not have the required items of furniture as specified in the National Minimum Standards. 2. 3 4. YA16 YA26 YA24 Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wells Road Care Home DS0000002259.V288233.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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