Inspection on 23/10/07 for Wensley House

This inspection was carried out on 23rd October 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 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 22/10/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Wensley House Bell Common Epping Essex CM16 4DL Lead Inspector Sarah Hannington & Carolyn Delaney Unannounced Inspection 23rd October 2007 12:00 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.V351268.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.V351268.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 Manager post vacant Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Wensley House DS0000066442.V351268.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) 6th December 2006 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. Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site inspection had two inspectors visit and focused on all Key standards and any requirements and recommendations from the last key inspection. The inspection took 8 hours to complete. The manager and proprietor were present throughout the inspection. Prior to this inspection CSCI (Commission for Social Care Inspection) sent out surveys to all interested parties. Information collated from surveys and discussion during the site inspection will be reflected within this report. During the inspection it was possible to speak to eight residents and one relative, their comments are reflected throughout this report. Additionally the proprietor was sent a (AQAA) Annual Quality Assurance Assessment form by CSCI that asked how well the service is meeting the needs of the people who live at Wensley House. We also looked at what else we already know about the home and compared it with what the proprioter had said on the (AQAA). As part of its equalities and diversity work the Commission has also established an external group made up of people who use services. This group is known as the Experts by Experience. The expert by experience provides a source of expert advice and guidance for CSCI. It ensures that CSCI has properly considered equalities and diversity issues in all its work and comes from the perspective of people who use care services. Some members come from usercontrolled organisations; others are individuals who use social care services. One member of the expert by experience group attended the site visit. This expert spent their time speaking with residents and staff. Quotes from a report written by the expert by experience and their discussion with the proprietor during the site inspection will be reflected within this report. The proprietor was fully supportive of requirements and recommendations discussed at the end of the inspection process and showed a commitment to improving standards expected. What the service does well: Visitors are made welcome by the staff at Wensley house and are offered refreshments and food. Staff are good at their jobs. Residents spoken with felt that they had confidence in the staff that supported them. Relatives spoken with felt that staff were caring and dedicated to their role. The environment was clean, odour free and practical for the needs of the residents and each individual room was personalised, clean and homely. Wensley House DS0000066442.V351268.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.V351268.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.V351268.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): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls in the admission process means that not all residents needs can be met by the staff team in the home. The home does not provide intermediate care. EVIDENCE: The manager provided evidence that a statement of purpose and service users guide to enable individuals to make an informed choice, that the home could support their needs is in place. Overall good assessments have been carried out for most of the newly admitted residents, by the manager and documentation as expected was in place. Although documentation was generally good, there was little evidence to suggest that consultation was part of this process or that individuals had been written to confirming that the home could support them fully. One individual, who was recently admitted, had not been pre-assessed by the manager or any member of staff of the home and when looking through documentation for this individual it was basic, Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 9 incomplete in places and lacked information as required. The resident in question was admitted against the criteria for which the home is registered, namely their primary need was stated as dementia and additionally staff have had no specific training in this area. The proprietor states on his AQAA that, ‘all service users are assessed before admission and a care plan is drawn up on the bases of the assessment, for service users placed by a council, the care plan submitted by the social worker is also taken into consideration when drawing up a care plan.’ The majority of relatives and residents expressed an opinion that they had received enough information from the home prior to being offered a placement. Wensley House DS0000066442.V351268.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): 7,8,9 and 10 Quality in this outcome area is adequate. Judgement has been made using available evidence including a visit to this service. Lack of consultation with residents with residents and subsequent shortfalls in care planning means that they may not have their care needs met in full. EVIDENCE: Case tracking of care plans took place in respect of fifteen residents and other records were looked at as a part of this process. Basic instructions were available for staff and daily log sheets are completed. For the majority of the resident’s assessments all areas of health care for individuals had been identified and some care plans evidenced that pre-assessments, initial assessment/Com 5 (information from the referring social worker), were basic but reflective of each other. There was very little evidence on the care plans that consultation had gone ahead with the individual, their representative or relative. The proprietor states on his AQAA that he needs to improve and ‘Update careplans on a far more regular basis in consultation with the service user and Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 11 / or representative.’ and ‘Hopefully, get the involvement and views of other interested parties in preparation careplans etc.’ Most care plans give a comprehensive breakdown of each residents’ needs including associated risks, however in some care plans and risk assessments they did not clearly evidence this. There was little or no consistency amongst some of the care plans tracked. Whilst there were some good practices around the recording of residents’ basic care needs, such as recording of weight, nutrition, seeing GP regularly, district nurses and chiropody, for some residents there were still areas of information that were poorly recorded and some assessed needs did not have a required risk assessment. Some information was limited, particularly around issues such as dementia, behaviour, pressure sores, mobility and communication. These all needed further information to ensure that the health, safety and welfare of the individual are supported and protected. At this present time the manager is reviewing and re-writing all the care plans. Discussion took place that it may be a good idea if key workers and staff, that have been in post for a considerable time, be involved in this process as they have the background knowledge which would make the care plans more person centred and holistic. The majority of residents expressed an opinion that they are well supported In the care provided by staff and the majority of relatives expressed that the support was usually to a good standard, although there could be more consultation over care plans with themselves and their relatives. A Monitored medication dosage system is in place for each resident. Medication is stored in a lockable cabinet and a new dedicated medication fridge has been obtained. The administration records were being maintained in accordance with agreed procedures. Record sheets had been signed for with no omissions or gaps when medications are booked in or returned and documentation is consistently recorded and accurate. Discussion with staff evidenced they knew procedures well and were aware of individual need and that they had been trained. Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A basic activity programme is not meeting the needs of all of the residents in the home and outcomes are unsatisfactory. Regular nutritious meals are being provided and are reflective of indivdual choice. EVIDENCE: Since the last inspection there has been an entertainer bought in once a week. It was pleasing to see that nearly all of the residents participated and seemed to be enjoying this session. It is positive that the home has made this move towards improving activities, however there still needs to be further development in this area. Speaking with staff, they do carry out activities when they have time in between their busy schedule. This could be improved upon by having a dedicated period of time or to include a specific activities coordinator to organise this and for the documentation to be in place that evidences that this is going ahead. Additionally some thought about 1-1 time for those residents who do not want to be included in a group activity or the on going stimulation needed for one resident who has dementia needs further development. Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 13 It was positive to note that care plans contained residents individual preferences, however there was no evidence to show that these request had been put into place. On surveys returned by the majority of relatives and residents there were a number of comments around the area of activities, these included ‘the recent activity-armchair exercise to music is very enjoyable and I think there is the occasional bingo session. Other than this to my knowledge there is nothing, I would like to see attention given to this aspect’, ‘over a number of years my relative to my knowledge has been out once for a short outing’, ‘more activities would be welcome, card games, video, demonstrations, exercise classes, church services – anything to pass the time!’, ‘more daily activities would be appreciated by most residents.’ and ‘ Would like to see more money spent on activities and entertainment for the relatives.’ The expert by experience stated that, ‘All the residents with whom I spoke indicated that they were very satisfied with their accommodation and with the care they received. They said, and I saw, that visitors were freely welcomed. Residents were complimentary about the attitude of staff, confirming that staff listened to them and heeded their wishes and preferences. They said they enjoyed certain activities on offer in the home, which they referred to as “the visit of the Music Man” who was due to attend on the afternoon of the day of the inspection. Those activities proved to be variations of “music and movement” and other exercises designed to encourage alertness and physical activity. Nearly all the residents participated fully’ Relatives and residents spoken with on the site visit, gave high praise of the staff team and care they received. Some of the residents expressed that the staff are not just carrying out daily routines but often have a general laugh with them, which brightens their day. Observation showed that interaction between staff and residents is good. The meals offered to residents are appealing home cooked meals, of high quality, reflecting individuals tastes, dietary needs and were praised by all residents spoken with. The dining room is set out and presented nicely. The majority of residents commented that they were very happy with the food supplied, one resident commented that, ‘there is very nice food available, good and healthy.’ The proprietor states in his AQAA that, ‘The menu sheets will indicate that the service users have been consulted with reference to their meals and indicate the availablity of a choice.’ Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The informal approach to the management of complaints does not evidence that residents or relatives receive satisfactory outcomes to the issues raised. Shortfalls in staff training in safe guarding vulnerable adults could potentially put residents at risk. EVIDENCE: There have been no formal complaints received by the home or made to CSCI or any other agency since the last inspection. Due to no complaints being received, the proprietor informed us that there is no format in place for the investigation of complaints. The new manager has reviewed the complaints policy and procedures, which are to a good standard and the complaints procedure is set out clearly in the service user guide. The proprietor states on his AQAA that, ‘We have no official complaints in the last year, service users and their representatives have discussed problems with me or senior staff and all issues have been resolved to the satisfaction of all parties concerned through dialogue.’ The majority of relatives and residents stated that they knew how to and who to go to if they needed to make a complaint. However a few comments from relatives stated that they would like a little more information or to be kept updated on issues such as ‘ our family would like to be kept up-to-date with Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 15 medication reviews’ and ‘ my relatives condition makes its necessary to drink a lot, I feel this is not always attended to and my relative is so forgetful that if they are not reminded to drink they won’t.’ A dedicated complaints and concerns folder should be in place so as if a complaint or a concern is received it can be easily tracked or recorded by any member of staff and allow the manager to monitor the progression of an issue, with each stage it takes. Awareness around concerns, complaints and how to record and recognise the importance of tracking these should be discussed with all staff, as they are aware but not fully knowledgeable around the homes policy and procedures or what to do if they received one. The manager has carried out an in house safe guarding training session, which raised staff awareness. Planned accredited training should also follow to improve staff awareness. Safe guarding training forms part of the induction process. Information and documentation around safeguarding referrals, Regulation 37’s and Regulation 26 visits were not available. The manager did not have access to any of this documentation, so was unable to track or monitor the frequency of incidents occurring within the home. All this vital documentation should be kept on site and available for the manager and made available for inspection purposes. Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 16 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home environment provides a clean, comfortable and safe environment in which to live in. EVIDENCE: The home is well looked after and maintained. There are no odours throughout the home and it is cosy, homely and comfortable. Numbers of toilets and bathrooms are sufficient, however there are a large number of bathrooms not in use due to individuals’ mobility and support needs. The proprietor needs to develop bathing facilities and he is going to address these issues as part of his business plan. Feed back from the expert by experience was that, ‘the property adjoins Epping Forest, a green belt area, and overlooks a cricket field. The home stands in its own grounds, which are accessible by wheelchair. The perimeter Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 17 of the property is marked by recently installed metal railings and an electronically controlled sliding gate across the entrance drive, giving access to generous parking space at the front of the home. There are five shared and twenty-one single bedrooms. Many of the rooms were visited, and were seen to be clean and well decorated. In none of the rooms seen was there any odour of urine. Residents’ rooms were personalised with memorabilia such as photographs and ornaments. There are adequate bathroom and toilet facilities. There is a conservatory, a lounge, a dining/sitting room and a small separate dining room on the ground floor. All these rooms offer a pleasant environment.’ The proprietor in his AQAA states that, ‘The Home meets the required standards as far as toilets, bathrooms and other requirements as far as room sizes are concerned. The Home is painted and decorated and maintained to a high standard, the furniture is of good quality and replacements will be made as necessary. The Home is cleaned and maintained to a high standard and every effort is made to keep it odour free. All equipment used in The Home is purchased to ensure that very high standards are met, to ensure we minimise the risk of infection. The Home is well maintained with beautiful gardens and plenty of seating areas and seats in the gardens for services users, their friends and relatives with a fair amount of space for parking.’ There were no health and safety issue raised at this site inspection. The proprietor has just installed a new call system, fire alarm system, all inside lighting has been improved upon and new water tanks have been installed. Outside the grounds have been landscaped, there is new outside lighting, new fences and electronic gates have been fitted for extra security. Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff on duty, their experience and skill is able to meet the needs of residents. Recruitment procedures are to a good and they are to a good standard which protects the health, safety and welfare of residents. EVIDENCE: Staff files were reviewed and recruitment records evidenced that application forms were completed, interviews were held, two references obtained, criminal records bureau checks undertaken and proof of ID and photograph kept. Contracts of conditions of service and job descriptions were issued to new staff. Copies of training certificates were also kept on staff files. In general staff training and induction is to a good standard, however accredited training needs to be implemented with regard to safeguarding and dementia training, which is relevant and necessary to support the needs of the residents. Rota’s evidenced that sufficient care staff and senior cover are regularly on duty, additionally, a cook, domestic, laundry and maintenance staff provided additional support. However although there was a maintenance person employed and on the rota, this staff member has recently just left and this needs to be recruited for as soon as possible. Additionally there is no activities coordinator in place. Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 19 The proprietor states on his AQAA that, ‘our staffing numbers reflect the assessed needs of the service users using the Residential Forum … at present 83 of our staff have their NVQ Level 2 or better with the rest of the staff already enrolled to follow the NVQ Level 2 course.’ Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 20 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management systems in general are improving and are starting to ensure that the home is run in the best interests of the residents. EVIDENCE: The proprietor has recently employed a new manager for the home and the residents have already benefited from this change. The manager has got the qualifications and experience to demonstrate that he is competent in running Wensley House. Through discussion the manager evidenced that he has a good philosophy of care and has good management strategies that he wants to implement to create a transparent and good ethos throughout the home. Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 21 The manager has made good progress to ensure that good practices amongst the team are implemented and that awareness is raised, by holding regular staff meetings, training sessions, regular supervision and efficiently organising the day to day running of the home. However, the manager has no open access to some of the vital documentation needed to fulfil his role effectively. Clearly the manager not having access to this documentation or being able to discharge fully his expected role has resulted in a failure to meet some aspects of the Care Standards. The proprietor has demonstrated that he is good at acknowledging the shortfalls discussed and does still maintain that the residents are well looked after and safe. Policy, procedures and documentation evidence that resident finances are protected. The proprietor states in his AQAA that, ‘We submit detailed accounts periodically to the service users or their representatives and keep all the back up documentation such as hairdressing invoices in the office so that service users or their representatives can verify the accuracy of the invoices.’ Overall there were no immediate concerns over Health and Safety or relevant certificates, only that information relating to this could be better organised so that it is available in one folder and easier to track. The proprietor states in his AQAA that,’ As far as Health & Safety is concerned, we have made sure that systems like the Fire Alarm System is working properly by having the system completely updated. We have also engaged the services of a specialist company in the field of Health & Safety to guide us and give us the necessary advise and backing to ensure that we carry out all our duties as required … to help us with carrying out all the necessay risk assessments and provide the staff with the necessary advise and guidance as far as Health & Safety matters are concerned.’ The manager has made sure that Safeguarding is given high priority by carrying out training sessions and raising staff awareness. The manager is also currently reviewing all policies and guidance to underpin good practice and will evidence that the home is run in the best interest of the residents. Therefore also securing the health, welfare, safety and protection of residents. Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 22 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 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 23 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 Schedule 3 (1)(a)(b) 14 (1)(a)(b)(d) 15 (1) Requirement To ensure that all new residents are only admitted on the basis of a full assessment and that the home is able to met the individual needs. Additionally that the home is appropriately registered for the persons needs that has been referred. To ensure staff receive training appropriate to the work they are to perform. This refers to the need for staff to be trained in dementia care for which the home is not registered for but has admitted one resident with their primary need being dementia. 3 OP7 14 (c)(2)(a)(b) To ensure care plans contain all actions required by staff to meet each person’s need. Where possible residents and their supporters should be involved in the development of care plans, and this should 29/02/08 Timescale for action 31/12/07 2 OP4 12 (1)(a)(b) 10 (1) 29/02/08 Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 24 be evidenced. 4 OP12 16 (2)(m)(n) To ensure residents all to receive a varied programme of `in house` and community based activities. This is a repeat requirement from the last inspection. 06/12/06 5 OP18 13(6) To ensure the protection of residents, all staff must complete appropriate accredited training in safe guarding awareness and the home’s procedures for responding to suspicion of abuse. That this documentation is in place and available for inspection. To ensure that all records and essential documentation is in place and available for inspection. To ensure that the reporting of notifiable incidents takes place and that relevant documentation is sent to the Commission. To ensure that Regulation 26 visits take place and the resulting documentation is in place and available for inspection. 29/02/08 29/02/08 6 OP37 Regulation 17(1)(3)(b) Regulation 37(1)(a)(b)( c) (d)(e)(f)(g) (2) Schedule 4 (5) Regulation 17 (2) Regulation 26 (1)(3)(1)(2) (4)(a)(b)(c) 31/12/07 7 OP38 31/12/07 8 OP38 31/12/07 Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP16 Good Practice Recommendations Documentation to be in place that encourages people to express any complaints and concerns, and this should be in place and available for inspection. Wensley House DS0000066442.V351268.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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.V351268.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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