CARE HOMES FOR OLDER PEOPLE
Wentworth Croft Bretton Gate Peterborough PE3 9UZ Lead Inspector
Elaine Boismier Key Unannounced Inspection 4th July 2006 10:15 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 Wentworth Croft DS0000024308.V296173.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. Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Wentworth Croft Address Bretton Gate Peterborough PE3 9UZ 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) 01733 269200 01733 269665 www.bupa.com BUPA Care Homes (CFHCare) Limited Mr Alan Bristow Care Home 134 Category(ies) of Dementia - over 65 years of age (37), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (32), Old age, not falling within any other category (127), Physical disability (2), Physical disability over 65 years of age (60), Terminally ill over 65 years of age (60) Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. 9. Two named individuals with Physical Disabilities who are below 65 years of age (PD) for the duration of their residency No more than 92 beds to provide nursing care Service users who are over 65 years of age, not falling within any other category (OP), not exceeding 127 places for the duration of Condition 1 & 8 Terminally ill over 65 years of age (TI(E)) not exceeding 60 places for the duration of Condition 1 Physical disability over 65 years of age (PD(E)) not exceeding 60 places for the duration of Condition 1 & 8 Mental disorder, excluding learning disability or dementia over 65 years of age (MD(E)) not exceeding 32 places Dementia over 65 years of age (DE(E)) not exceeding 37 places. The maximum number of persons accommodated in the home at any one time is 134 5 named individuals over 65 years of age with dementia for the duration of their residency only (DE(E)) 15th November 2005 Date of last inspection Brief Description of the Service: Wentworth Croft is situated in Peterborough City 4 miles from the city centre and is accessible by public transport. The home is situated in well-maintained and landscaped gardens including an enclosed garden for those living at Harvester House. Wentworth Croft is arranged into 4 houses: Yeoman and Hayward provide up to 60 places for people over 65 years of age who have nursing needs; Harvester provides up to 32 places for people over 65 years of age with both nursing and mental health needs; Woolsack provides up to 42 places for people over 65 years of age with personal care needs. The Commission for Social Care Inspection has approved variations of registration for 2 named people below 65 years of age with personal care needs and 7 additional people, over 65 years of age, with mental health needs, to live at the home.
Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 5 Fees range from £343.19 to £673.10. Additional costs include those for chiropody, hairdressing and private taxis. A copy of the inspection report is available on request at the home or via the CSCI website. Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. This summary includes findings of an unannounced inspection carried out on 6th March 2006;a follow up unannounced inspection that was carried out on 22nd March 2006 and correspondence between the home and the Commission regarding self-medication practices. The purpose of the inspection of 6th March 2006 was to assess the home’s compliance with an immediate requirement made at the time of an announced inspection of 15th November 2005 when it was found that medication was not stored in a safe manner. Medication was found again to be kept in an unsafe manner. The Commission, however, took a reasonable and proportionate view not to take further action at that point and decided to carry forward the requirement. To assess compliance with this requirement (that was carried forward from 6th March 2006) an unannounced inspection was carried out on 20th March 2006 and it was considered that the requirement had been met. The home Manager sought advice from the Commission, in a letter of 24th March 2006, about the issue of residents who chose to keep medication, including creams, in their own rooms, for self-medication purposes. The Commission advised the home Manager, in a letter of 28th March 2006, that such practice should be based on risk assessments and in line with good policies and procedures. This is the key inspection of Wentworth Croft for 2006/7. The inspection was unannounced and was carried out by two Inspectors (one of whom was the Pharmacist Inspector) between 10:15 and 18:45 and took 8.5 hours to complete. Hayward House, Harvester House and Woolsack House were visited on this occasion. On the day of the inspection there were 132 residents living at the home and 10 of these were spoken to, although not all of the residents, due to their condition, were able to tell the Inspectors about their views of the home. Staff were also spoken to, as were visitors, documentation was seen and a tour of the premises was carried out. Information provided to the Commission, since the last inspection of November 2005, has been included also in this report. Wentworth Croft provides an adequate standard of service provision that has the potential of becoming a good service. This potential improvement could be made should action be taken to meet the requirements and any
Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 7 recommendations made in this report, and by any other agencies. Any such improvements made should also be sustained through the home’s management and quality systems to maintain such an improved standard of service provision. What the service does well: What has improved since the last inspection?
The home has met both requirements and considered the recommendation made following the November inspection and has improved also in other areas as follows: • The standard of preadmission information about prospective residents had improved, due to the experience and qualifications of the person who had carried out such assessments. This requirement has been met. The standard of care plan documentation has improved. An immediate requirement was made for medication to be stored safely. An unannounced inspection during March 2006 indicated that this requirement had been met. The garden areas of both Woolsack and Harvester House have been upgraded.
DS0000024308.V296173.R01.S.doc Version 5.2 Page 8 • • • Wentworth Croft • A recommendation was made to find out if the numbers of staff were adequate to meet the level of needs of the residents. The Manager reported that all residents were assessed to establish their level of needs. The majority of people spoken to considerd that there was a sufficient number of staff on duty at all times. This recommendation has been considered. What they could do better:
The home could do better in the following areas: • • • • • Preadmission information about the home should be improved upon. A recommendation has been made about this. Staff should follow the instructions as written in the care plans. A recommendation has been made about this. A recommendation has been made for the standard of care plan documentation to continue to be improved upon. Staff must help residents maintain their standard of personal care. A requirement has been made about this. Procedures in use for the safe handling of medicines and the standard of record keeping for the administration of medicines must be improved. Requirements have been made about this Residents must be offered a choice of how to live. A requirement has been made about this. The standard of meat provided, (and any other food that residents are not satisfied with) should be considered, as residents said that the meat was “tough” and “gristly”. A recommendation has been made about this. A recommendation has been made for a review of staffing arrangements at mealtimes. The standard of communication between intermediate care staff and the home staff should be improved upon. A recommendation has been made about this. The home should have 50 of care staff with NVQ level 2, or equivalent. A recommendation has been made about this. Required information about staff must be obtained before they commence duties and this information is to be kept at the home. A requirement has been made about this.
DS0000024308.V296173.R01.S.doc Version 5.2 Page 9 • • • • • • Wentworth Croft • Staff must attend training to include protection of vulnerable adults against abuse training. A requirement has been made. 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. Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 10 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 Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&6 There is adequate information for prospective residents to know what the home can provide. EVIDENCE: Information provided in the care plans that were examined indicated that people have a full assessment of their needs before they move into the home and this was confirmed by staff. This recommendation has been considered. Residents, admitted for intermediate care, however, informed the Inspector that prior to moving in they were not given information, about where they were going to. One resident thought she was being sent to a hotel rather than a care home. A recommendation has been made for this standard of preadmission information to be improved upon. Wentworth Croft provides 8 places for people assessed to have short term rehabilitation needs i.e. intermediate care. Discussions with residents admitted for intermediate care indicated that, on the whole, they were aware of the goals of their rehabilitation and these were detailed in their care files.
Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 12 Discussion with staff of both the home and intermediate care team indicated that communication between both parties was not always clear. There appeared some confusion about individual and shared responsibilities, of both the intermediate care team and staff of the home, in carrying out the care of the residents. A recommendation has been made about this. Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 The standard of health care is adequate although standards of medication practices are poor. EVIDENCE: Ten residents care files were seen and evidence suggests that the standard of care plan documentation has improved although details should be more specific. For example the use of the word “regular” was used and no specific details of how often care should be provided for oral hygiene were available (see also standard 16 of this report). A recommendation has been made for this improvement to continue. During a discussion with a resident it was noted that the bed table, with a drink provided, was out of reach, although the care plan detailed that the resident’s table should be placed within reach. Examination of other residents’ care files detailed their preferred time of going to bed and getting up. Residents indicated that such care plans were not always followed by staff (see also standard 12 of this report). A recommendation has been made about this. Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 14 Residents’ care files recorded visits made by GPs, district nurses and community psychiatric nurses. The Manager and staff reported that there is a very low incidence of residents who have acquired pressure sores whilst living at Wentworth Croft. The Manager and staff reported that an increase of specialist beds, for people assessed to have nursing needs, has been brought for the home. Specialist mental health needs of residents were observed to be well met by staff. Discussions with visitors to the home and observation of residents indicated that oral hygiene, nail and hair care was not always carried out. A requirement has been made about this. An immediate requirement was made at the time of the inspection of November 2005 for medication to be stored in a safe way. An unannounced inspection of 6th March 2006 demonstrated that this requirement had not been met in full. Evidence found during a further unannounced inspection of 20th March 2006 indicated that this requirement had been met. During the visit by a pharmacist inspector medication was seen to be provided for a resident to take at a later time at a day care centre. It was assembled by a nurse into an unlabelled container and, after prompting by an unqualified person, was then transferred into an envelope. This is an unsafe method of providing medication to a resident and an immediate requirement was made. It is disappointing that some of the deficiencies in the safe handling and recording of medication noted on the last inspection by a pharmacist inspector are outstanding following this inspection, even though an acceptable action plan was received to indicate that these requirements would be met. Procedures for the ordering and supply of medicines are satisfactory but could improved since staff do not have sight of the original signed prescription before it is dispensed. This lack of control may be the reason why some medicines are overstocked and other times where medication supplies have run out before being re-ordered. It is evident the some staff do not follow the home’s own written policies and procedures. Records relating to the ordering, receipt and disposal of medicines were inspected. Hand-written changes or additions to instructions for prescribed medicines did not indicate who made the change or when. Case tracking of care progress notes in many cases gave no indication of the reason for changes in prescribed instructions. Records of the prescribing and administration of medicines to some service users on Haywood were continued from their hospital stay. No separate record related to the use of medicines in the home and there was no clear indication of when staff in the home had started to use the forms. Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 15 There were an unacceptable number of gaps in the administration records for medicines on both Hayward House and Harvester House giving no indication of whether medicines had been administered or not. There were a worrying number of cases where medication was recorded as omitted since it was “out of stock”, sometimes up to a period of 10 days. Staff must take control of the ordering process to ensure sufficient medication is in stock for the continued treatment of residents. If stock does run out, staff must obtain further supplies promptly so that residents are not put at risk. Storage facilities in the areas inspected were adequate and were secure at the time of this inspection. Stock levels were slightly higher than expected and there was evidence of over-ordering. Evidence was also found of the retention of some medicines beyond their prescribed period of use. The temperature of the storage facilities in all three units was above the recommended maximum of 25C. The temperatures were not recorded in all houses visited. Temperatures must be monitored and recorded daily to ensure medicines are stored in acceptable environmental conditions. If the temperature is consistently above 25C then steps must be taken to resolve this. The temperatures of the refrigerators used for the storage of medicines were satisfactory. It is a matter of concern that temperature records showed temperatures outside the recommended ranges without action taken by staff to investigate the performance of the fridge or the suitability for use of the medicines stored there. Storage facilities for medicines controlled under the Misuse of Drugs Act 1971, and associated regulations, complied with the Misuse of Drugs (Safe Custody) Regulations 1973. Records of the administration of controlled drugs were satisfactory, but there were some recording errors which meant the recorded stock balances were inaccurate. Records of receipt do no indicate the full name and address of the supplier as required by the Misuse of Drugs Regulations. It is essential that records are made clearly and accurately. There is a good level of staff training for them to administer medicines safely and a formal assessment of competence is completed and documented, although not all staff have received this training. Residents considered that staff were kind and treated them with respect and dignity. Staff were seen to interact with residents in an appropriate manner and knocked on doors before entering residents’ bedrooms. Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Residents live an adequate quality of life that could be improved upon. EVIDENCE: Residents confirmed that they were able to choose what to wear and were given the choice to join in activities provided. A resident said “ I can do what I like here”. Residents’ care files detailed their preferred times of when they liked to go to bed and when they liked to get up although information provided by a number of residents indicated that their choice about this matter was not always valued. A resident reported that they “fitted in” with what the staff said; another resident reported that they had been woken up at 6:30 am to be informed that they had been in bed “long enough”. A requirement has been made about this. It was noted that residents had guests visiting and it was also noted that residents going out of the home with their visitors. The majority of residents confirmed that they chose who to handle their monies, including their personal monies. Visitors to the home indicated that
Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 17 access to advocacy services is made on behalf of residents. Information about the Alzheimer’s society was available on the notice board of Harvester House. Residents reported that there was a choice of menu available. Lunch time was observed on Harvester House and it was noted staff were sitting down when helping residents with their meal. Visitors considered that there was insufficient number of staff to help residents with their meals although staff considered this not to be the case. On the day of the inspection residents’ needs were being met during the lunch time period. A recommendation has been made for a review of meal times and staffing arrangements. There were mixed views from residents about the standard of food provided at the home. A recurring concern was about the poor standard of the meat; this was described by residents to be tough” and “gristly”. A recommendation has been made about this. Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 18 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Good systems are in place for residents to be listened to and be safe from abuse. EVIDENCE: A copy of the home’s written response, to a complaint made by a resident, was received on 28th June 2006. Information in this response demonstrated that the home had taken appropriate action to investigate the complaint in an open, listening and transparent way. A copy of a relatives’ meeting held in March 2006 notes positive response of the Manager to relatives’ concern about the cleanliness of the home. The majority of residents stated that if they were unhappy about something they knew who to speak to. Those residents who have made a concern/complaint felt that they were listened to and satisfied with the action the home took. Visitors considered that recently they felt listened to and considered satisfactory action had been taken in response to the majority of their complaints. Since the inspection of November 2005 there have been two separate strategy meetings held under the local procedures for the protection of vulnerable adults against abuse. The home has demonstrated to both the Commission and local authorities a good knowledge of reporting of allegations of abuse and has
Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 19 demonstrated a willingness to work in a co-operative way to protect residents from harm. All residents spoken to, and able to say so, felt safe living at Wentworth Croft. (See also standard 30 of this report). Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Residents live in a home that is clean and adequately furnished and decorated. EVIDENCE: Since the last inspection of November both communal outside areas of Woolsack and Harvester Houses have been upgraded, to provide patio areas with garden furniture and flowers, for residents and their guests to visit and enjoy. Discussion with the Manager and staff indicated that the home operates a refurbishment programme and arrangements have been made to replace floor coverings in the satellite kitchens of all 4 Houses and replace corridor carpets on Woolsack House. The Commission for Social Care Inspection received notification of an outbreak of an infection and information detailed in this notification suggested that appropriate action had been taken to prevent further spread of this infection. A
Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 21 copy of the regulation 26 visit, for February 2006 notes that this reported infection was resolved. On the day of the inspection the 3 Houses that were visited were generally clean and there was no offensive smells. Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 The standard of training for staff and staff recruitment procedures is adequate but could be improved upon. EVIDENCE: Staff considered that there were sufficient numbers of staff on duty to meet the needs of residents. Residents considered that they did not have to wait long for staff to attend to their calls for assistance. (see also standard 15 of this report). According to the Manager the home has 47 care staff with NVQ level 2, or equivalent. A recommendation has been made for the home to have 50 of care staff with NVQ level 2, or equivalent. Five staff files were examined and required information was available in 4 of the 5 files. For the remaining file there was no evidence of the current registration status of the nurse and no copies of this person’s qualifications, including nursing qualifications. A requirement has been made. Five staff training files that were seen indicated staff attend induction and foundation training. Staff reported that they had attended training in medication, food hygiene, dementia care and urinary catheter care. Discussions with staff indicated that not all staff have attended training in protection of vulnerable adults against abuse. A requirement has been made.
Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33,35 & 38 The management of the home is good. EVIDENCE: The Registered Manager, Mr Alan Bristow, was appointed to manage Wentworth Croft, in October 2004 and was registered by the Commission in March 2005. He has a range of experience in mental health care and management, in hospitals and the community. Prior to moving to Wentworth Croft he was the Registered Manager of the Gables, Eastrea, a care home for individuals over 65 years of age with mental health needs. He has received an award for dementia care at national level. Since the last inspection of November he has attended a course to increase his awareness about the changes in inspection and regulation. Positive comments were made by staff; they considered Mr Bristow to be supportive of them and responsive to any questions they might pose to him.
Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 24 The Commission receives copies of the monthly regulation 26 visit reports. The information provided includes evidence of audits of records, discussions with staff and residents and reviews of the environment of the home. The Manager provided examples of ongoing quality assurance systems that are in place that includes audits of care plan documentation; arrangements to improve activities for residents with mental health needs; improving staff training facilities and, in response to a previous recommendation, a review of residents’ levels of needs. The home is currently responsible for the safe keeping of 88 residents’ personal monies. Records of these balances were seen and were satisfactory. Records for fire checks, emergency lighting checks, hot water temperature checks and service checks for hoists were seen and these were satisfactory. The home has had an inspection carried out by the fire safety officer in March 2006 and the Manager’s written response to this fire safety inspection report noted what action had been taken to make sure the home was free from the risk of fire. Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 25 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 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 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 26 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. 1. Standard OP8 Regulation 12(1)(b) Requirement The Registered Person must ensure that service users receive an appropriate standard of personal care. The Registered Person must ensure that medication for residents to take on short-term absence from the home is provided for them in an identifiable container supplied by a pharmacist. An immediate requirement was made. The Registered Person must ensure that suitable arrangements are in place for the storage, handling, recording and safe administration of medicines. The Registered Person must ensure that staff adhere to the written procedures for the safe handling and recording of medicines. The Registered Person must ensure that service users are offered choices of how they wish to live.
DS0000024308.V296173.R01.S.doc Timescale for action 14/07/06 2. OP9 12(1) & 13(2) 05/07/06 3. OP9 13(2) 17(1)(a), Sch 3(3)(i) 13(2) 01/08/06 4. OP9 01/08/06 5. OP12 12(2) 01/08/06 Wentworth Croft Version 5.2 Page 27 6. OP29 17(2) &19 7. OP30 13(6) The Registered Person must ensure that required information about staff is obtained before they commence work and this information is kept at the home. The Registered Person must ensure that staff attend training in protection of vulnerable adults from abuse. 01/08/06 01/09/06 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 OP7 OP9 Good Practice Recommendations All prospective service users should have information about the home before living there. Staff should follow the care plan when providing care. The improved standard of care plan documentation should continue to be improved upon. Hand-written changes or additions to instructions should be signed and dated by the person making the change. Clear justification for such changes must be made in care progress notes or care plans. A procedure should be in place for staff to have sight of the original signed prescription before it is dispensed. The standard of food, including meat, should be reviewed. The staffing arrangements at meal times should be reviewed. The communication between staff at the home should be improved upon. The home should have 50 of care staff with NVQ level 2 or equivalent. 5. 6. 7. 8. 9. OP9 OP15 OP27 OP27 OP28 Wentworth Croft DS0000024308.V296173.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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