Inspection on 22/10/08 for Wensley House

This inspection was carried out on 22nd October 2008.

CSCI found this care home to be providing an Adequate service.

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

Wensley House 23/10/07

Wensley House 06/12/06

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

CARE HOMES FOR OLDER PEOPLE Wensley House Bell Common Epping Essex CM16 4DL Lead Inspector Diane Roberts Unannounced Inspection 22nd October 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wensley House DS0000066442.V372876.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. Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wensley House Address Bell Common Epping Essex CM16 4DL 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) 01992 573117 01992 560479 jp.beling@btinternet.com Beling & Co. Ltd Sharon Allison Osborne Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 31 persons) 23rd October 2007 Date of last inspection Brief Description of the Service: Wensley House is a fully detached two storey building on the outskirts of Epping Town, close to Epping Forest and backing on to Epping Cricket Ground. Nearest shopping facilities are in the town of Epping. Public transport passes close by the home. The home is registered to accommodate thirty-one elderly people (over the age of 65). Accommodation is provided in twenty-one single bedrooms and five shared bedrooms, situated on both floors of the home. Communal space comprises of a conservatory, one dining/sitting room, a further small dining room and one lounge all on the ground floor, there is also a lounge/dining room on the first floor, which is designated as a visitors lounge. Access between floors is provided by a passenger shaft lift. The home is reached by a long private driveway leading to ample visitor car parking to the front of the building. Fully accessible, well maintained, gardens are provided for residents to the front, side and rear of the property. There is a statement of purpose and service users guide available for perspective residents and their relatives to browse through. This is to enable individuals to consider if Wensley house is suitable and can support their specific needs. Fees range from £425.00 shared room to £600.00 for a single room. Residents do not have to pay for toiletries but do pay for newspapers, chiropody and hairdressing etc. Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The site visit was undertaken over a six-hour period as part of the routine key inspection. Both the manager and deputy manager were available during the inspection and it was possible to meet the proprietor. The manager submitted an Annual Quality Assurance Assessment as required prior the site visit. This details their own assessment of what they do well, what could be done better and what needs improving. This information was considered as part of the inspection process and reflected as part of the report. Prior to the site visit, the manager was sent a variety of surveys to distribute and that asked questions that were relevant for each group, such as for people who use the service, relatives, staff, and healthcare professionals. Four responses were received from people who use the service, three from relatives/carers, three from staff, two from health professionals and one from a care manager/social worker. On the day it was possible to speak to four residents and three staff in addition to the management team. A tour of the home was undertaken and a range of records relating to the home and the services offered were reviewed. What the service does well: Residents’ benefit from a core stable staff team that are generally well trained and are resident led in their approach to the provision of care. Residents are happy with the staff team and comments included ‘ they are kind and caring’ and ‘they are patient and do not rush you’. The manager has an open approach to complaints and residents can be assured that they would be listened to. Residents have regular opportunities to speak to the manager, which they like. The home provides a nice environment in which to live and it continues to be upgraded. The manager is keen to ensue that that service is run in the best interests of the residents. Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 6 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. Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents cannot be fully assured that their needs would be assessed before coming into the home, potentially affecting outcomes for them. EVIDENCE: The manager has a basic pre admission assessment form in place that is completed for prospective residents to the home. Either the manager or her deputies complete these assessments. These were randomly sampled from recent admissions to the home. They were seen to have been completed fully, giving adequate information, but due to the nature of the form they gave somewhat limited picture about the actual individual. These forms would benefit from having a more person centred approach to the information being gathered, leading to a more person centred care planning system. The manager in her AQAA states under - what they could do better ‘ prepare a profile for each service user prior to admission so that all staff are made aware Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 9 of the service users needs and lifestyle’. In addition to the assessment, where appropriate, the team had copies of the social services referral information. Residents spoken to regarding their admission to the home said that ‘ I did not have an assessment at home, the manager assessed me once I was in Wensley and I was asked what I liked and what I did not like and what I could do and what I needed help with’, ‘a member of staff spent time with me going through the service users guide and telling me about the home’, ‘I was made to feel very welcome’, ‘I think that I have settled here, I have not seen the service users guide, not that I know of’ and ‘ I came here for respite before and they treated me so well I came back permanently’. The majority of residents who commented in surveys said that they had received sufficient information prior to and on admission to the home. Whilst residents are being pre –assessed prior to coming in to this home, much more than they were in the past, there is still some evidence that this is not 100 and requires more attention. The manager in her AQAA sates that ‘ all residents are assessed prior to admission’. Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Outcomes for some residents in the home could be affected by shortfalls in care planning and delivery. EVIDENCE: The manager has a care planning system in place that she has been developing since she came into post earlier in the year. The quality of the care plans was seen to be variable, as in some cases the information provided to care staff, in order to support and care for residents, was too basic or generalised. This was discussed with the manager, as in many areas of the care plan, it did not reflect the individual, their choice or opinion and their detailed needs. More work is needed on developing a person centred approach to care planning. On the whole residents had care plans in place that related to their identified needs but again the detail was limited. The care plans were seen to be up to date and reviewed regularly. The manager in her AQAA states that this is an area that the team have improved upon in the last year. Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 11 Short term care plans need to be in place for residents with acute needs, for example, those with infections or needing pain management as residents were observed to have specific/acute needs and had no care plan in place to give guidance for staff. Staff complete daily records which primarily gave information on dietary intake and whether residents had appeared to have slept well. Again these need developing further, so that they reflect the actual care provided and how the residents is within themselves, so they can be used as a key part of the monthly evaluation of the care plan. Residents who commented on the care provided said that ‘the staff are very helpful and caring, they do not rush you and are patient’, ‘if you use the buzzer the staff come quickly’, ‘the staff know how to look after me very well’, ‘the staff are caring and objective, I like it when they know me well’ and ‘ the staff are helpful, nothing is too much trouble’. Records showed that residents were receiving input from health care specialists and timely visits from their GP. The weighing of residents was inconsistent and the manager reported that the sit on scales had been broken for a while and they expected them to be fixed very soon. Some residents had not been weighed since July and others not on admission. The manager does not currently have a nutritional risk assessment in place but is giving this consideration and reported that they had no residents with weight loss concerns at the current time. No residents in the home were suffering from pressure sores and the residents were observed to have pressure-relieving equipment in place. Residents were seen to have a range of risk assessments within their care plans. These were seen to be up to date but on occasions residents, through observation and discussion, were noted to have bed rails in place without a full risk assessment or assessments were in place for manual handling and staff were not following the documented advice, i.e. using one member of staff when the assessment states that two should be used. This already had been raised with care staff at a meeting in June 2008. Risk assessments were again noted to be generalised and more work needs to be done to ensure that they have sufficient detail regarding the risk and its management and that they relate to the individuals needs. The medication management for the home was reviewed with the manager. Since arriving at the home the manager has been steadily working through residents medication reviews and it was evident, when reviewing the recording sheets, that this is needed as residents were seen to be on a lot of prescribed medication, laxatives and in some cases, long-term antibiotics, when the team did not know the rational for this. Records showed that where residents have refused medication, their GP had been informed. The recording system was seen to be maintained in good order with the medication being correctly checked in and signed for. The team do managed some controlled medications and these were checked and in one instance found to be incorrect with the Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 12 record and medication present not tallying. The manager subsequently undertook and= investigation and it was found that the staff member responsible had not followed procedure in signing for the administration of a controlled drug. The Commission is satisfied with the way that the manager has dealt with this matter. Interaction between staff and residents was seen and heard to be appropriate and friendly with staff seen to be respecting residents’ privacy and dignity. Wensley House DS0000066442.V372876.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have a generally good activities programme and meals service, although individual needs may not always be met. EVIDENCE: From observation and discussion with residents and staff, it is clear that the routines of the day are residents led. Residents say that ‘ you can spend your time how and where you want’, ‘we stay up later to watch television in the lounge’, ‘you are asked when if you want to get up and if you say no, they leave you for longer’ and ‘you can spend your time how you wish and you have choice about when you want to do things’. From discussion with staff, they said that ‘ we only put people to bed if they want to go, if they want to stay up the night staff will help them’ and ‘the residents have breakfast at all different times, when it suits them’. The manager in her AQAA states that ‘ residents have the freedom to come and go as they please and be visited by family and friends at any time’. Residents were observed to be spending time both in their bedrooms and in the lounges during the day. Residents were also observed to be taking breakfast later, from choice. Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 14 Residents care plans are variable in relation to their social care. Some were seen to contain quite good information on social preferences but this did not always inform or lead to a plan of care that may improve outcomes for residents. More could be done to focus on promoting wellbeing, self worth and independence for the individual through activities. Whilst the group activities in the home are acceptable, individual needs may not always be met. Some residents were seen to have good life histories in place that would help to inform a social care plan, but others did not have these. The manager reported that she is still working on getting these completed with input from the families and evidence was seen of this. From discussion with some residents, who did not have these in place, more could be done to work with the resident themselves on this aspect of their care. The manager does not currently employ an activities co-ordinator but is giving this some consideration. The manager reports that activities are decided upon by getting all the residents together and asking what they would like to go. The manager has minutes of this to show that she has met regularly with residents and relatives to discuss this subject. Minutes showed that overall residents were in agreement that the activities in the home had improved and that they like being involved in deciding what would happen. Activities currently include: bingo, piano playing, films, sing a long, karaoke, outside entertainers, a music therapist and church services. Residents who commented said that ‘there are not activities every day, I think they rely on outside entertainers coming in’, ‘ one residents plays the piano and the other residents enjoy a dance and a sing’, ‘we do get the odd entertainer’, ‘we all enjoy the music lady and playing instruments’ and ‘ we could do with more social activities, more quizzes would be good’. Residents who commented in surveys said that there were either usually or sometimes activities they could take part in. The manager in her AQQA sates that whilst they have improved this aspect of life in the home, this is still an area for improvement and she plans to continue to develop this. Mealtimes in the home were observed to be relaxed and residents benefited from having well set dining tables with condiments etc. and at breakfast, pots of tea and jugs of milk etc. Menus are planned following feedback from the residents and this was partially evident in the minutes of meetings held with them. The daily menu is clearly displayed in the dining room. Residents who commented on the food said that ‘ the food is ok’, ‘the food is very good’, ‘there is a good choice but often, by the time it gets to you it is cold’, ‘you have choice and you can eat where you want’ ‘ the tables are laid nicely’, ‘ the staff come round every day and tell you want is on the menu’, ‘ there is plenty of food and supper is like another meal’, ‘ there are plenty of drinks available, you can have squash between the tea rounds’, ‘the food is a bit ordinary, but there is plenty and its of a good quality’, ‘the food is often not hot by the time you get it as they have so much to dish out’ and ‘ they would make you something else if you did not like what was on the menu’. The manager in her Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 15 AQAA states that ‘ all meals are prepared on the premises and we use fresh produce from local suppliers’. Menu sheets seen showed that residents are making choices about the menu and being provided with alternatives. The manager should consult with residents further on the issue of food temperatures to see if this can be addressed. Wensley House DS0000066442.V372876.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that they would be listened to if they had a concern and that, as far as possible, they would be protected from adult abuse. EVIDENCE: The manager has a complaints procedure in place that is on display in the main hallway and is outlined in the Service Users Guide. Residents spoken to said that ‘ the manager is always around so I would raise anything with her’, ‘ the manager comes in every evening to make sure that we are alright, so we get plenty of opportunity to see her’ and ‘any complaints, I would see the manager, she always asks us our opinion on things.’ The manager reports that since she has been in post she has not received any complaints but does have a system in place for recording and dealing with any that are raised. The manager in her AQAA states that they have improved by ‘ maintaining a dialogue with all parties concerned and kept them informed of all events that may affect them, we also pay attention to what is being said and take any appropriate action. The manager has in place up to date adult protection procedures along with the local authority guidance. Staff records show that all the staff are up to date with adult protection training and staff spoken demonstrated an understanding of adult protection matters. The manager is an accredited trainer on this subject, through Action on Elder Abuse. Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 17 The new manager has been sending Regulation 37 notices to us as required, notifying us of any incidents etc. that could affect the health and wellbeing of residents. Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a good, safe environment that meets their needs. EVIDENCE: A tour of the home was undertaken with the deputy manager. All the communal areas were viewed along with a large number of the bedrooms. The home is decorated to a good to high standard and the residents will also soon benefit from a large new lounge extension, which opens onto the garden and has much more natural daylight than the original oak panelled lounge. A new toilet has also been made between the two lounges and this has very good disabled access. The home also has a small conservatory, which is regularly used by residents as it houses the piano. There are plans in place to refurbish this area, as it does get cold in the winter months. Bedrooms were seen to be comfortable and personalised with furniture and belongings. Where appropriate, residents were seen to have the specialist equipment that they Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 19 needed. Bathrooms were seen and are fit for purpose and a range of different bathing aids are available. The home benefits from having several outdoors areas including a small central courtyard that is popular during the warmer weather. Overall the home was seen to be very clean and odours were only noted in specific rooms and did not impact on the home as a whole. The staff have equipment available to help them manager odours as best as possible. The home is well maintained and a maintenance man works at the home full time, undertaking the required checks and records. The manager has completed a fire safety risk assessment and this was up to date along with all the maintenance certification for fire safety /fighting equipment. Records showed that staff attend fire drills and the alarms are tested regularly. Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a stable core staff team that is generally well trained and recruited. EVIDENCE: Since the new manager has started at the home, there has been an increase turnover in staff but this has now settled and the manager has recruited. The home is nearly up to a full compliment of staff, with four new care staff due to start in the near future. At the current time shifts are being covered by the staff already at the home with occasional agency use. The manager also likes to undertake some hands on shifts. The manager is currently providing 4 care staff and 1 senior for 26 residents during the day and into the early evening, with 2 awake staff on at night. None of the residents spoken to, or who commented said that there was an issue with the number of staff on duty. The rota was reviewed and it shows that there are generally four staff covering the late shift, not five. Residents who commented said that ‘ I like the staff, they are kind’ and ‘I feel that there are enough staff around, you could always have more, but its fine. The manager in her AQAA states that she uses the Residential Forum tool to decide staffing levels based upon the dependency of residents. Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 21 The manager currently has 63 of her care staff team with an NVQ level two qualification or above and the rest of the care team are currently undertaking it. This means the home is well above the recommended 50 . Recruitment files for new staff at the home were checked at random and found to be generally in good order with the required checks and documentation in place. However the manager needs to ensure that copies of staff identification is on file along with any ‘right to work’ permits that may be required for overseas staff. Files showed that staff have undergone probationary periods before being given a full contract and that they have received an induction. Most of the staff have an NVQ and if not they are undertaking common induction standards along with a basic home induction. The manager has the full Skills for Care resources available. The manager in her AQQA states that they could further develop their induction training for new staff. Since starting at the home the manager has been providing staff with training in a range of subjects. Records show that there is very good compliance with manual handling, infection control, fire safety and adult protection. Only a few staff have attended recent health and safety and first aid training and this needs to be addressed. Compliance is better with food hygiene. The manager in her AQAA says that they ‘plan to provide more training courses such as food hygiene etc’. Consideration should be given to care plan training and training in conditions associated with old age. Wensley House DS0000066442.V372876.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): Quality in this outcome area is good . This judgement has been made using available evidence including a visit to this service. The manager is developing the staff team and services in the home to ensure that it is run in the best interests of residents. EVIDENCE: The manager has been working at the home since June 2008. She has work in care settings for a long while, working her way up to management, starting as a care assistant and has an NVQ level 4 and the registered manager’s award. It is positive to note that she is also trained to train staff in manual handling, adult protection and dementia. The manager has applied to us to be the manager and is awaiting the outcome of her interview. The staff speak positively about the new manager and comments include ‘the manager is very helpful and works non stop, she also deals with issue very well’ and ‘the new manager is very good and things are improving’. The Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 23 manager has been holding meetings with residents, relatives and staff and the minute’s show that feedback is being sort from all parties on the running of the home. Minutes also helped to demonstrate the progression that the team has made under the new management structure. The manager has yet to develop a quality assurance system based on obtaining feedback from interested parties. A medication audit has been developed and systems are in place in the kitchen to ensure good food hygiene. At the current time the manager does not hold any monies on behalf of residents, using an invoice system for any expenses incurred. A review of the accident records shows that these are fully completed and where necessary, there is evidence of follow up. The manager has contact with the local falls prevention team when required. A random sample of safety and maintenance certification for equipment and fixtures in the home were found to be in good order and up to date. Wensley House DS0000066442.V372876.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 3 Wensley House DS0000066442.V372876.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 OP3 Regulation 14 Requirement To ensure that all new residents are only admitted on the basis of a full assessment so that the home is able to meet their individual needs. Residents care plans need to contain sufficient detail and be individual to them, to enable staff to care for residents in line with their wishes. Residents need to have the appropriate risk assessments in place to ensure risks are reduced as much as possible and staff should take note of the advice and follow it. Residents weight needs to be regularly monitored and their nutritional status risk assessed to ensure that dietary needs are met. Staff must follow the medication procedures that the manager has in place, to ensure resident safety and accountability in the home. A robust recruitment procedure needs to be in place to ensure residents safety and meet DS0000066442.V372876.R01.S.doc Timescale for action 30/11/08 2. OP7 15 31/12/08 3. OP8 13 30/11/08 4. OP8 13 14/12/08 5. OP9 13 14/12/08 6. OP29 19 14/12/08 Wensley House Version 5.2 Page 26 7. OP4 12 8. OP33 24 regulatory requirements. This relates to the identification of staff and permits to work. Ensure staff receive training appropriate to the work they are to perform. This is a repeat requirement. Previous date being 29/02/08. Develop a quality assurance system for the home, based on seeking the views of all interested parties so that services in the home continue to improve. 28/02/09 30/01/09 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. 2. 3. 4. Refer to Standard OP3 OP7 OP12 Good Practice Recommendations A review of the assessment documentation would be of value in order to develop a more person centred approach. A more person centred approach to care planning should continue to be developed, so that residents preferences and wishes are more evident. Continue to consult with residents in order to further develop the social activities programme and develop individual social care plans. Consult with residents about the quality of the food and take any action required. OP15 Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wensley House DS0000066442.V372876.R01.S.doc Version 5.2 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. 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