Inspection on 07/09/07 for Wentworth House

This inspection was carried out on 7th September 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

Wentworth House 22/12/06

Wentworth House 24/02/06

Wentworth House 27/10/05

Wentworth House 10/11/04

Wentworth House 26/05/04

Wentworth House 28/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Wentworth House 8 Blantyre Road Swinton Gtr Manchester M27 5ER Lead Inspector Adele Berriman Unannounced Inspection 11:00 7 September 2007 th 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 House DS0000008339.V338899.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 House DS0000008339.V338899.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wentworth House Address 8 Blantyre Road Swinton Gtr Manchester M27 5ER 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) 0161 793 9090 Wentworthhouse@aol.com Mr Antonio Belvedere Mrs Christine Belvedere Mr Antonio Belvedere Care Home 19 Category(ies) of Learning disability over 65 years of age (1), Old registration, with number age, not falling within any other category (18) of places Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service user category (LD) (E) is specifically for one named individual. If this person leaves the service user category will revert to (OP). 22nd December 2006 Date of last inspection Brief Description of the Service: Wentworth House is a home that provides residential care for up to 19 service users over the age of 65. The home is situated on a quiet residential road in the Swinton area of Salford. The home is situated close to local amenities and close to public transport routes. Bedrooms are situated on both the ground and first floors of the accommodation. A passenger lift serves both floors. There are several communal lounge/dining rooms that are situated on the ground floor of the accommodation. The home continues with ongoing refurbishment to provide a pleasant living environment. The cost of the service is between £395.00 and £426.00 per week. Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit to the service was unannounced and took place on Friday, 7th September 2007, and a further brief visit was made to the service on 14th September. Information contained in this report was also gained about the service from information sent prior to the visit by the manager of the service and from survey forms sent to residents and given to staff. During the visit the inspector spoke to several residents, a district nurse visiting the service, a senior member of the care staff and the managers/proprietors of the service. A selection of care plans, staff files, policies, procedures and records were assessed during the visit. A tour of some areas of the building, including bedrooms, bathrooms and communal areas took place. The home’s newly built kitchen was also visited. At the time of the inspection the home was in the process of being extended and refurbished to include more en-suite facilities in residents’ bedrooms and new carpets and décor. Residents were pleased with their newly refurbished bedrooms. The home was very clean and tidy and was furnished to meet the needs of the residents. Throughout the visit the inspector observed a pleasant atmosphere around the home with lots of conversation taking place between residents, staff and visitors. During the visit residents spoke positively about the care and support they received from the care team. Six residents and/or their relatives completed survey forms. The information given on these forms was positive about the service. One resident commented ‘how lovely the staff are’ and a relative wrote ‘I cannot fault the care my sister receives.’ Survey forms demonstrated that people had received enough information about the home before they moved in, knew how to make a complaint and that the home is always fresh and clean. Four people said that staff were always available when you needed them and two people said they usually were. Three people said that they always received the care and support they needed and three people said that they usually did. Three people said that they always liked the meals at the home and three people said that they usually did. Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Residents’ needs and preferences relating to social and recreation need to be fully recorded to ensure that staff are aware of and are able to meet these needs. The medication policy should contain detailed information about the procedures for all aspects of the administration process of medication. The current policy does not contain sufficient detail to support people who are able to fully or partly administer their own medication and this may result residents’ independence not being supported. Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 7 Staff files need to contain evidence to fully demonstrate that all appropriate checks and references have been sought prior to a person commencing employment, to ensure that only people appropriate to carry out the role are employed. Improvements need to be made to ensure that all accidents/incidents and occurrences specified in Regulation 37 of the Care Home Regulations 2001 are reported appropriately to the Commission. Regular testing of fire detection systems and escape routes in operation must take place to minimise the risk to people’s wellbeing. Several good practice recommendations have been made in this report. 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. Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Management at the home ensure that individuals’ needs and wishes can be met prior to them moving into the home. EVIDENCE: Prior to a person moving into the home, a manager of the service assesses their needs and wishes to ensure that the home has the facilities to meet them. Once the resident has moved into Wentworth House a ‘daily living and needs assessment’ is completed and documents the resident’s needs and wishes in all aspects of their day to day life. Information from these assessments informs the resident’s individual care plan. Copies of these assessments were seen on residents’ individual files. Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 10 Wentworth House does not provide intermediate care facilities. Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Care plans ensure that residents’ personal and health care needs are identified and met. EVIDENCE: Each resident had an individual file that contained personal information and their care plan. There was evidence that these had been reviewed and updated. A selection of residents’ files were assessed. The newly revised formats for the care plans were clearly written and contained detailed information to inform staff on what needs a person had and what actions were needed to meet these needs. For example, ‘check hourly through the night to ensure her safety’ and ‘carer will remain with (X) whilst in the bath and will use bath hoist to get (X) in and out of the bath.’ Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 12 The documents detailed people’s needs and wishes relating to personal care, dietary, mobility, medication, night needs and mental health; however, there was no opportunity to record residents’ social and recreational needs. It is essential that care plans contain information about all aspects of residents’ day to day life. Daily records were maintained of what care and support had been offered and delivered to individuals. The majority of these records were detailed and informative. One particular style of handwriting in the records was extremely difficult to read. It is essential that records are legible to ensure that people are aware of any changing needs and wishes of the residents. Records demonstrated that residents had access to local health professionals on a regular basis and all visits were recorded on residents’ individual files. During the visit a dentist visited several residents. A district nurse who visited the service on a regular basis made very positive comments about the personal care residents received at the home, and also commented “the communication is excellent with the manager and the staff.” A relative of one resident wrote “they do not hesitate to call her doctor, dentist, optician or the chiropody service if it is needed, plus informing me before and after the medical attention needed.” A written procedure was available for staff to follow in the event of a resident being admitted to hospital, stating what information needed to be shared and ensuring that the resident’s next of kin were informed. A policy for medication and its administration was in operation that gave details around how and when medication was administered by staff. However, the policy did not give guidance on the storage and administration of controlled drugs nor did it give guidance for when residents were able to self-administer or partly administer their medication. It is essential that the medication policy contains detailed information of all aspects of medication storage and administration. All medication was stored in an appropriate lockable cabinet. A local pharmacy supplies the home with medication with the majority of this medication is dispensed in a ‘vena link’ system. Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 13 Pre-printed Medication Administration Records (MAR’s) were in use to record what medication had been administered. A selection of these records were assessed. The MAR’s gave the opportunity for staff to record the amount and date that the medication was delivered, however, this information had not been recorded. The records demonstrated that residents’ medication was being administered, however, on some occasions staff had written ‘o’ which represented omitted but had failed to record why the medication had been omitted. It is essential that up to date records of all medication omitted are maintained at all times. Staff were observed addressing residents in a dignified manner. Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are encouraged opportunities are available. to maintain their independence and social EVIDENCE: Some activities were taking place around the home. There is a dominoes group that meets on a weekly basis, facilitated by a volunteer carrying out a Duke of Edinburgh Award. Monthly ‘music for health’ sessions have been introduced which enable residents to participate in activities to promote health and wellbeing. A manager of the service said that these sessions have been very successful as everyone is able to participate. It is also planned to form a choir group for residents in preparation for Christmas. An entertainer also visits on a monthly basis. It was not the practice of the home to document when a resident has carried out a social activity. It is strongly recommended that records of all activities are maintained to ensure that an accurate record of what has occurred in the residents’ day is maintained. Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 15 Four people who responded to the service user survey forms stated that there were usually activities arranged at the home for them to take part in; two people said that there sometimes was and one person said that there never was. One person wrote that they felt there should be activities for the residents. The managers at the home stated that the provision of activities available was to be reviewed in the near future, once the refurbishment is completed. A representative from a local Church of England visits the home on a monthly basis and a representative from a local Roman Catholic Church visits fortnightly to enable residents to participate in communion. Three residents who spoke to the inspector said that their friends and family were welcome to visit at any time. Information about external advocacy services was available at the home. Information from survey forms demonstrated that staff listen and act on what residents say. Meals are served in communal dining rooms situated on the ground floor of the building. A menu was available and staff demonstrated knowledge of people’s likes and dislikes. The manager stated that the current menus would be reviewed in the near future, once the refurbishment had been completed. During the visit residents stated that they enjoyed the food that was served. Three people stated on their survey form that they always liked the meals served and three people stated that they usually did. Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident in the home’s complaints procedures. The Safeguarding Policy provided informative information for staff to protect residents. EVIDENCE: There was a complaints procedure available in the home. Details of the procedure were also included in information given to prospective residents. A manager stated that any concerns raised by a resident would be recorded in their personal file. No complaints had been received by the Commission for Social Care Inspection about the service since the previous inspection. All but one person who completed a survey form stated that they knew how to make a complaint. Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 17 The home had reviewed its Adult Protection policy since the previous inspection. The policy was informative and gave staff examples of what constitutes abuse. However, the policy did not directly refer to Salford Social Services Safeguarding Adults joint agency procedure, a copy of which was available at the home. It is essential that the home’s policy on adult protection refers directly to Salford Social Services Safeguarding Adults procedure to ensure that staff are aware of the exact procedure to follow in the event of witnessing/suspecting abuse. It is strongly recommended that staff have the opportunity to attend an awareness training session on this procedure. Wentworth House DS0000008339.V338899.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): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home provides a safe, clean, comfortable environment for residents to live in. EVIDENCE: At the time of the visit construction workers were in the process of completing a major refurbishment of the home. One bedroom was awaiting redecoration and all others had been pleasantly decorated; the majority of rooms had been fitted with new carpets or alternative floor covering. The refurbishment has included the provision of en-suite facilities, including a toilet, wash basin and a level access shower facility. Several residents had moved into new bedrooms and one resident in particular said that she was “thrilled” with her room. Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 19 The back garden and patio area of the home were not accessible to residents at the time of the visit as construction of the patio and an outside decking area was still taking place. Outside, chairs and a bench were available at the front of the building for people to sit. A relative of a resident had commented in a survey form that the extension and renovations seemed to be taking a very long time. The manager of the service stated that the work should have been completed some time ago, however, it was now nearing completion. The manager stated that the home had been awarded an improvement grant which was to be used towards the funding of a loop system to be fitted in a communal lounge to enhance people’s hearing. The environment was homely, well maintained and communal areas were furnished to meet the needs of the residents. The home was very clean and free from malodour. Everybody who completed a service user survey stated that the home was always fresh and clean. One relative wrote “the home is very nicely furnished and decorated, my sister’s room is lovely, there are never any ‘smells’ that I have been aware of, the home is very fresh and kept to a high standard. This is very satisfactory to me, for the wellbeing and health of my sister.” Wentworth House DS0000008339.V338899.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): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents’ needs were met by the number of experienced staff on duty. However, records did not reflect staff training or that appropriate recruitment procedures had taken place. EVIDENCE: At the time of the visit two carers, a senior carer and the managers of the home were on duty to meet the needs of the 19 residents. Residents commented positively about the care and support they received from the staff team. A senior member of staff was spoken to who demonstrated a detailed awareness of the residents’ needs and wishes. A cook and domestic staff were employed to meet the needs of the service, however, both these members of staff were on sick leave. A manager explained that, in their absence, the senior staff on duty were attending to the cooking and an extra carer was on duty to carry out laundry and domestic duties. Residents spoken to during the visit spoke positively about the staff team and staff were seen to engage in a positive, non-discriminatory manner with residents. Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 21 The service had a procedure for the recruitment of staff that stated the complete recruitment process, from advertising vacancies to the commencement of employment. The procedure also stated that prospective candidates would only be offered a post following successful completion of a Criminal Records Bureau/POVA First check, two written references and evidence that the applicant was legally entitled to work in the United Kingdom. A selection of files for the most recently recruited staff members were assessed and each file contained evidence that a successful Criminal Records Bureau check had been received. However, some files did not contain all the information required, for example, two staff files did not contain the references required and another contained a reference that had been written the previous year. Another staff file contained an application form that had not been completed in full. It is essential that staff files demonstrate that all appropriate checks have been carried out and references received prior to a person commencing employment to demonstrate that risk to the health and wellbeing of all has been minimised. Information received from the service prior to the visit taking place stated that the service could organise training for staff more effectively and that the plans for improvement in the next 12 months was to “identify key training provider to meet our training needs.” Further information supplied by the manager of the service demonstrated that weekly development training sessions for staff would be commencing on 9th November 2007 and that the training would be delivered by the manager and visiting tutors. The service is registered with the Skills for Care national minimum dataset in social care and has adopted the Skills for Care common induction standards. Staff stated in their survey forms that they received appropriate training for their role and there was evidence that staff had attended fire training, however, there was no record of the date or person who had carried out the training recorded. Little information about what training staff had undertaken was available at the home. It is essential that an up to date record is maintained of all training undertaken by staff. Four members of staff completed staff survey forms. Two staff stated that they usually have the right support, experience and knowledge to meet the different needs of the residents and two staff said that they always do. Staff stated that they often met with their manager to discuss how they are working. Staff wrote positive comments about what they thought the service did well, for example, one staff member wrote “we care about people” and another wrote “we look after the residents physically, mentally and emotionally.” Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 22 One staff member wrote that the service could do better their “paperwork, although it has improved a lot we are working hard to get everything in place.” Wentworth House DS0000008339.V338899.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home is run in the best interests of the residents. EVIDENCE: The home is owned and managed by Mr and Mrs Belvedere, who are both trained nurses and have extensive experience in working with older people. In order to gain the views of the people who use the service, the service has a questionnaire that is circulated to residents and their relatives and/or their representatives. The manager of the service stated that the way in which people’s views on the service were sought would be under review following the refurbishment of the home. Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 24 Several residents weekly personal allowances were managed by the management of the home. All monies are entered into a dedicated residents’ account and records of all transactions were maintained along with receipts for purchases. Records demonstrated that staff were receiving formal supervision for their role. Several of these records were assessed and documented clear information about what was discussed during the session and an example of good practice was recorded of a particular policy being discussed and clear objectives set for the next session. Polices and procedures were in place to maintain the health and wellbeing of residents and staff and there was evidence that some policies, for example, Fire Safety, Health and Safety and Control of Substances Hazardous to Health had been updated since the previous inspection. The manager of the service stated that other procedures would be updated following the refurbishment of the service. During the previous inspection discussion took place regarding the need for a policy and guidance to be developed to support staff when dealing with residents who are challenging the service and restraint. The manager of the service stated that these polices would be developed in the near future. Records demonstrated that regular servicing and maintenance of moving and handling equipment and the passenger lift were taking place. A new hot water and heating system had been installed throughout the building as part of the ongoing refurbishment. Records demonstrated that not all accidents and occurrences that had occurred at the home had been reported to the Commission under Regulation 37 of the Care Home Regulations 2001. It is essential that all occurrences listed in the Regulation are reported to the Commission immediately. Regular checks of the hot water provision throughout the building were recorded, along with weekly checks of the fire detection system. However, records demonstrated that a test of the fire detection system was overdue. An immediate test of this system was requested which the manager completed immediately. There was inappropriate signage displayed to inform people of how to evacuate the building in the event of a fire and there was no lighting to the fire evacuation stairwell from the first floor. The manager of the service went and purchased a bulb for the stairwell and appropriate signage to rectify the situation whilst the visit was taking place. Wentworth House DS0000008339.V338899.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 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 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 2 2 Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15 Requirement Timescale for action 08/11/07 2 OP9 13 Residents’ needs and preferences relating to social and recreation activities must be recorded in their individual plan of care to ensure that people are aware of and are able to meet these needs. 07/09/07 Information and guidance relating to controlled drugs and residents who are able to administer/part administer their own medication needs to be contained in the services medication policy and procedures. In the event of a resident not taking their medication, a full record of why this medication was omitted must be made. All staff records need to demonstrate that all appropriate checks have been made prior to a person commencing employment and contain all the documents listed in Schedule 2 of the Care Homes Regulations 2001. (Previous timescale of 22/12/06 not met). DS0000008339.V338899.R01.S.doc 3 OP29 19 07/09/07 Wentworth House Version 5.2 Page 27 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. 4 Standard OP37 Regulation 12 Requirement Timescale for action 07/09/07 5 OP38 12 The home is required to notify the Commission for Social Care Inspection of all notifiable incidents occurring at the home. (Previous timescale of 14/02/07 not met). To ensure that residents are 07/09/07 protected from the risk of fire, the fire detection system must be tested on a weekly basis to ensure that it is operational at all times. Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 28 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 Refer to Standard OP7 OP12 Good Practice Recommendations It is strongly recommended that all records written and maintained at the home are written in a manner understandable to all. It is recommended that consultation takes place on a regular basis regarding what activities and social opportunities are made available to residents. It is further recommended that any activities undertaken by a resident are recorded. It is strongly recommended that a senior member of staff/ manager of the service attends an awareness course on Salford Social Services joint agency safeguarding policy and that the home’s adult protection policy clearly refers staff to Salford Social Services safeguarding policy. 3 OP18 Wentworth House DS0000008339.V338899.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local Office 11th Floor, West Point 501 Chester Road Old Trafford Manchester M16 9HU 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. 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