Inspection on 02/02/07 for Welshwood Manor

This inspection was carried out on 2nd February 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Welshwood Manor 30/01/06

Welshwood Manor 11/10/05

Welshwood Manor 27/01/05

Welshwood Manor 26/05/04

Similar services:

Claremont House

Oak Ridge

Coopers Mill Ltd

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Paradise Lodge

Grangewood

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

CARE HOMES FOR OLDER PEOPLE Welshwood Manor 37 Welshwood Park Road Colchester Essex CO4 3HZ Lead Inspector Diana Green Unannounced Inspection 2nd February 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 Welshwood Manor DS0000015344.V329637.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. Welshwood Manor DS0000015344.V329637.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Welshwood Manor Address 37 Welshwood Park Road Colchester Essex CO4 3HZ 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) 01206 868483 01206 870615 welshwoodmanor@btconnect.com Davard Care Homes Limited Mr Robin Neal Pickering Care Home 32 Category(ies) of Learning disability (1), Learning disability over registration, with number 65 years of age (2), Old age, not falling within of places any other category (19), Physical disability (4), Physical disability over 65 years of age (32) Welshwood Manor DS0000015344.V329637.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. Persons of either sex, aged 55 years and over, who require nursing care by reason of a physical disability (not to exceed 4 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 32 persons) Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 19 persons) One person, under the age of 65 years, who requires care by reason of a physical disability and who also has a learning disability, whose name was made known to the Commission in May 2004 One service user, aged 90 years and over, who requires nursing care by reason of a physical disability who also has a learning disability, whose name was made known to the Commission in January 2005 One service user, aged 65 years and over, who requires nursing care by reason of a physical disability who also has a learning disability, whose name was made known to the Commission in January 2005 The total number of service users accommodated in the home must not exceed 32 persons 30th January 2006 Date of last inspection Brief Description of the Service: Welshwood Manor provides nursing and personal care with accommodation for up to 32 older people and 4 younger adults with a physical disability. Welshwood Manor is owned by a private organisation named Davard Care Homes Ltd. The home is located at the end of Welshwood Park Road, a quiet cul-de-sac to the north of Colchester and a short drive from the town centre. The home was opened in 1999 and comprises a three-storey property that has been extended to provide additional accommodation. Further upgrading of the premises has been completed recently to provide increased single en-suite accommodation and an additional communal room. There are 26 single en-suite bedrooms and 3 double bedrooms. There is a passenger lift. The fees range from £448.28 -£904.03 weekly. Additional costs apply for chiropody, toiletries, hairdressing and newspapers. This information was Welshwood Manor DS0000015344.V329637.R01.S.doc Version 5.2 Page 5 provided to the CSCI on 2/02/07. Welshwood Manor DS0000015344.V329637.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place on the 2/02/07 lasting 6.5 hours. The inspection process included: discussions with the registered manager, deputy manager, the chef, maintenance person, the activities coordinator, seven residents, two care staff, three relatives and feedback from health and social work professionals; a tour of the premises including a sample of residents’ rooms, bathrooms, communal areas, the kitchen, the laundry and the sluice-rooms; an inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Twenty-six standards were covered, four were commended and one recommendation made. The manager, deputy manager and staff were welcoming and helpful throughout the inspection. What the service does well: Welshwood Manor provides high standards of personal and nursing care. The environment is attractive and well maintained. The décor and furnishings were suitable for the client group. Some period pieces of furniture had been provided that particularly enhanced the appearance of the lounge/dining room. The manager has made a commitment to improve the quality of the service provided by regularly reviewing services with full involvement of residents and staff. Residents are encouraged to become involved in life at the home, some taking an active part in planning new developments such as garden planting schemes. There is excellent communication with relatives. Those spoken with said they were invited to social functions and kept well informed on all aspects of care of their loved ones. The workforce is stable meaning residents are cared for by people they know. There is an ongoing programme of training. Emphasis is placed on good teamwork. Staff are well motivated and supported through regular supervision. Welshwood Manor DS0000015344.V329637.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Welshwood Manor DS0000015344.V329637.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 Welshwood Manor DS0000015344.V329637.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, 2, 3, 6 Quality in this outcome area is good. Residents were well informed, had their needs assessed and were assured that they could be met prior to moving in to the home. The service does not offer intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A revised statement of purpose was provided. Both the statement of purpose and service user guide reflected the aims and objectives of the home. The statement of purpose was made available to prospective residents and was displayed in the entrance of the home together with the service user guide and Welshwood Manor DS0000015344.V329637.R01.S.doc Version 5.2 Page 10 previous inspection report. The statement of purpose offered a pre-admission assessment of needs by a registered nurse. New residents have a trial period of one calendar month provided to ensure they are comfortable in the home and it meets their expectations. Visitors spoken with say they were welcome to visit the home before their relative was admitted. The files of six residents were seen and each one had a pre-admission assessment dated before the resident was admitted to the home and signed by the manager or deputy manager. The assessments covered all areas of care needs including personal care, mobility, continence, nutrition and medication. Welshwood Manor DS0000015344.V329637.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 excellent There is a clear and consistent care planning system in place that involves residents and health and social care professionals and provides staff with comprehensive information ensuring residents’ personal and healthcare needs are appropriately met. The systems for administration of medicines are good with clear and comprehensive procedures in place that are well adhered to and ensure residents’ safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans of six residents were seen and all had evidence of monthly reviews undertaken. Welshwood Manor DS0000015344.V329637.R01.S.doc Version 5.2 Page 12 All the files contained risk assessments for daily activities undertaken by the residents. These included risk assessment for falls, use of bed rails, moving and handling, smoking and self-administration of medication where relevant. The records contained contact details of health and social care professionals involved with the care of the resident. These included the GP, social worker, chiropodist, district nurse, practice nurse, tissue viability nurse, leg ulcer nurse, and physiotherapist. There was also evidence that residents attended outpatient clinics, as needed for audiology and vascular services. Residents received annual eye tests at the home and a visiting dentist attended as needed. Regular weight monitoring was recorded with evidence that action was taken to provide soft diets and supplements or to refer to a dietician as needed Daily records were detailed and showed how residents were and what care had been given to them and confirmed their relatives were kept informed on all aspects care. The home had a policy and procedures for the safe administration of medicines. Guidance published by the Royal Pharmaceutical Society of Great Britain (RPSGB) was also available for staff guidance. Medication was stored in a trolley in a secure cupboard located in a quiet lounge on the first floor of the home. There was a controlled drug cupboard and a separate drug fridge. Systems for monitoring daily temperatures were in place. Medication was supplied by a local pharmacy in a monitored dosage system and checked against residents’ prescriptions by a registered nurse. The home had a contract with a licensed contractor for the disposal of medication as required for a care home with nursing. Stock levels were at an acceptable level. Separate storage was provided for controlled drugs. Records made since the previous inspection confirmed that the full name and address of the supplier was recorded in the dedicated register. Medicines administration records were well recorded and there was a photograph of the resident held with each resident’s MAR sheet. Registered nurses administered all medication: a list of their signatures and initials being maintained for checking against. Systems were also in place to ensure NMC Pin numbers were recorded and checked to ensure they were current. Manufacturers medication information was provided for individual medicines as indicated as good practice. Systems were in place for medication reviews to be undertaken, ensuring that all residents had a review of their medication at minimum six monthly. One resident was self-medicating and a risk assessment had been undertaken and lockable facilities provide for safe storage. Residents spoken with said that staff were respectful and kind towards them, preserving their privacy and dignity when providing personal care. Relatives also confirmed they could visit at anytime and could see their loved one in private. Typical comments made by residents included: “the home is lovely”; I’m looked after here”; “I’m very happy here”; “staff are lovely”; “they always do their best”. Welshwood Manor DS0000015344.V329637.R01.S.doc Version 5.2 Page 13 Welshwood Manor DS0000015344.V329637.R01.S.doc Version 5.2 Page 14 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. The social and therapeutic activities offered at the home met residents’ cultural needs and expectations and enhanced their daily lives. Visitors were warmly welcomed into the home. The home provided residents with a well-balanced and nutritious diet with choices acommodated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had employed a new activities co-ordinator who has worked at the home for a number of years as a care assistant and was well known to both residents and staff. A full and varied programme of activities was provided each weekday that comprised individual and group activities. Residents were free to attend as they choose. A lively game of ‘pass the parcel’ was arranged during the afternoon with assistance offered to those residents as needed. The activity stimulated light-hearted conversation between residents and provided exercise to improve their dexterity. Residents clearly enjoyed the game and Welshwood Manor DS0000015344.V329637.R01.S.doc Version 5.2 Page 15 were excited that they may win one of the prizes given. The pastimes arranged include ball games, movement to music, board games, skittles, quoits, reminiscence and light gardening such as potting bulbs. Each resident had a life history recorded and their social activity preferences recorded. Daily records of the activities undertaken were completed for each individual resident. Residents spoken with said they enjoyed the activities provided: one said they liked the karaoke and another liked the game of darts. There were a number of visitors who came and went in the home during the day. Several were spoken with and all said they were welcome at any time and that they were kept well informed about their relative. Outings to garden centres and visiting theatre groups were also arranged and a communion service held with visiting representatives of various faiths arranged as needed. Special themed days, for example an Italian day, a Hawaiian and a Tennis Day had been arranged where staff had dressed up and menus reflected the occasion. Residents and relatives spoken with said that they had really enjoyed the Christmas pantomime arranged by staff. Residents spoken with said they were able to choose the time of getting up, going to bed, what to wear and whether to take part in activities or not. Information on advocacy services was made available to residents in the home. Postal votes had been arranged for seven residents at the home. The kitchen was clean and well organised with food stocks plentiful. All opened food was stored appropriately and labelled and dated. The records of temperatures of refrigerators and freezers confirmed they were all functioning within safe limits for food storage. The menus offered a cooked breakfast daily and a choice of main meal and dessert each day. Lunch on the day of inspection was battered fish or cheese pizza with potato wedges or mashed potato and fresh and frozen vegetables. The dessert was fruit cocktail and cream or a choice of ice cream, yoghurts or fresh fruit. Residents spoken with said they had enjoyed their lunch. The cook had undertaken updated food hygiene training and had delegated responsibility for budgetary control. Threemonth meetings were arranged with residents to seek their views of the meals provided with action taken to adapt menus to suit their preferences. The records confirmed that weight monitoring was regularly undertaken and action taken to provide supplements as needed. Two residents files inspected detailed the close nutritional monitoring undertaken and as a result, the weight gained by both residents. Welshwood Manor DS0000015344.V329637.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. Appropriate policies, procedures and practices were in place to promote the protection of residents from abuse. Recent updated training provides assurance to residents that these will be adhered to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure that included the timescales within which complainants can expect a response. The complaints procedure had been reviewed in line with the CSCI’s policy and was included in the statement of purpose and displayed in the entrance of the home. No complaints had been received since the previous inspection. The home had a comprehensive policy and detailed procedures for safeguarding vulnerable adults. The records confirmed that all staff had received training at induction and updated training was provided regularly. Records inspected showed that appropriate pre-recruitment checks on new staff were undertaken prior to appointment (see standard 29). Welshwood Manor DS0000015344.V329637.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, 22, 24, 26 Quality in this outcome area is good. Welshwood Manor was safe, well maintained and had a very homely environment; residents’ rooms were individually furnished and equipped for their comfort and privacy. The large attractive gardens to the rear of the premises are accessible wheelchairs users. The home was clean and hygienic with safe infection control practices that were well adhered to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial inspection of the premises was made that included communal areas, several bathrooms, a number of residents’ rooms, the kitchen, the sluices and the laundry. Décor and furnishings were attractive and appropriate for the client group. The home was in a good state of maintenance and repair. No unpleasant odours were noted. Records provided evidence that the building Welshwood Manor DS0000015344.V329637.R01.S.doc Version 5.2 Page 18 complied with the requirements of the local fire and environmental health department. The gardens to the rear of the home were secure and accessible to wheelchair users. Grab rails had been fitted throughout the home and ramps, hoists and other mobility equipment was available to meet the needs of residents. Wheelchairs were provided and were well maintained. The home had a range of pressure relieving equipment in use to meet residents needs. Although registered for nineteen residents with nursing needs, the home had only six adjustable beds available. The home was clean and hygienic throughout with no malodorous smells. There were appropriate handwashing facilities in place to prevent the risk of infection and infection control practices were observed to be safe. All staff received regular infection control training. The manager had obtained a copy of the Department of Health’s publication ‘Infection Control for Care Homes’ and had reviewed the home’s policies and procedures in line with the guidance. The policy and procedures were comprehensive and included responsibilities of key personnel and a plan of action in the event of an outbreak of infection. During a recent outbreak of infection at the home the procedures had been implemented and were found to provide staff with clear guidance. Laundry and sluice facilities were located away from areas where food was prepared or eaten. The laundry was small but well organised. There were two washing machines, one with a sluice cycle and one tumble drier that were in working order. Red alginate bags were available for dealing with soiled linen. The home had two sluice disinfectors, one on each floor of the premises that were well maintained. Welshwood Manor DS0000015344.V329637.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 excellent. People who use this service can expect to be supported by adequate numbers of correctly recruited, well-trained staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels were appropriate to met the needs of the nineteen residents and comprised: 1 registered nurse 3 care assistants. The Deputy Manager was designated in charge; the registered manager also attended the inspection from 10:30hours. An activities coordinator was on duty from 10:30hours. Ancillary staff on duty comprised: the chef, 1 kitchen assistant, 1 laundry assistant, 2 domestic staff and 1 maintenance person. The manager, deputy manager and a registered nurse were qualified NVQ assessors. Nine staff had NVQ level 2 and eight (including assessors) had NVQ level 3. Additionally the remaining staff had bee booked to commence NVQ training during 2007. This represents sixty percent of the care staff and exceeds the minimum of fifty percent recommended in standard 28 of the National Minimum Standards. Welshwood Manor DS0000015344.V329637.R01.S.doc Version 5.2 Page 20 The files of two new members of staff were seen. Both had evidence that POVA 1st and criminal record bureau (CRB) had been undertaken prior to staff working at the home. Each file had documentary evidence that identification checks had been made and two satisfactory references had been received. The application forms included a full work history for each member of staff. An interview checklist was used during the interview to check the applicants’ responses. Both members of staff had been given a letter detailing their terms and conditions and a job description relevant to the post they were to undertake. The home had a training programme in place for all staff that included regular training in manual handling, fire safety, health and safety, Control of Substances Hazardous to Health (COSHH), first aid, food hygiene, first aid. Regular training sessions were also provided on subjects relevant to a care home with nursing for older people; for example, nutrition, pressure area care, wound care, protection of vulnerable adults. The manager had also accessed training in health and safety provided free from the Health & Safety Executive (HSE) & the local authority. Welshwood Manor DS0000015344.V329637.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, 33, 35, 38 Quality in this outcome area is excellent. The manager has a clear development plan and vision for the home that he has effectively communicated to residents, staff and relatives. Health and safety systems and practices are promoted and upheld to ensure the safety of residents and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager of the home is an experienced registered nurse and qualified nurse tutor with several years of management experience at the home and previous experience in managing care homes. The manager is Welshwood Manor DS0000015344.V329637.R01.S.doc Version 5.2 Page 22 supported by a deputy manager who is also a registered nurse. Positive feedback was received from residents and their representatives on the way they were involved and kept informed on all aspects in the home. Both the manager and deputy manager had attended regular updated training. The deputy manager was also undertaking NVQ level 4 training. Welshwood Manor had an annual plan for the home that reflected the aims and objectives of the home and focussed on the continued development of the service. The quality assurance framework included service user questionnaires that were distributed annually. The most recent questionnaire had been reviewed to provide residents’ views on how the home was meeting the National Minimum Standard outcome groups. Policies and procedures inspected were regularly reviewed and action from inspection reports was progressed within timescales as required. There was evidence from discussion with residents, their relatives and staff and previous knowledge of the home was run in the interests of service users. Since the previous key inspection, residents had been involved in reviewing the menus at the home during meetings held with the manager and the chef. This had been based on the commissions’ report on nutrition in care homes and had been followed up with training for staff. There was evidence from discussion with residents and their relatives that their views on the home were sought through frequent informal discussion with the manager. All residents had a relative or advocate to manage their monies on their behalf. The manager ensured that residents were provided with sufficient funds, liaising with social workers where there were issues of concern. Small amounts of cash were held in the safe for residents and were appropriately managed with records of receipts maintained. The systems for the management of three residents’ monies were inspected and amounts were confirmed as accurate. The home had a health and safety policy statement and there was evidence from the records and in discussion with the manager and staff that safe working practices were in place. All accidents, injuries and incidents were wellrecorded and appropriate action taken. Fire drill practice was observed during inspection and confirmed that all staff were clear on their roles and responsibilities in the event of a fire. Welshwood Manor DS0000015344.V329637.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 3 x 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x 3 x 3 x 4 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Welshwood Manor DS0000015344.V329637.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. Standard Regulation Requirement Timescale for action 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 OP24 Good Practice Recommendations Review the number of adjustable beds available at the home to ensure there are sufficient to meet the number and needs of residents. Welshwood Manor DS0000015344.V329637.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Welshwood Manor DS0000015344.V329637.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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