Inspection on 21/12/07 for Weybourne

This inspection was carried out on 21st December 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

Weybourne 20/01/09

Weybourne 27/02/07

Weybourne 24/11/05

Weybourne 25/05/05

Weybourne 06/12/04

Weybourne 02/07/04

Weybourne 25/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Weybourne Finchale Road Abbeywood London SE2 9AH Lead Inspector Lorraine Pumford Unannounced Inspection 21st December 2007 10:00 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 Weybourne DS0000006862.V341056.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. Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Weybourne Address Finchale Road Abbeywood London SE2 9AH 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) 020 8310 8674 0208 310 1953 jeanette.dwyer@kcht.org.uk www.kcht.org (2) vacant post Care Home 40 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 2007 Brief Description of the Service: Weybourne is a Home for 40 older people that is run by Kent Community Housing Trust (KCHT). The Home specialises in the care of people with dementia and the majority of the residents are in this category. The Home does not provide nursing care, but health professionals visit the Home on a regular basis. The Home is a purpose-built unit on two floors in Abbey Wood. There is a parade of shops nearby, and Abbey Wood Station is a short distance away. There are thirty-three rooms on the ground floor and a further seven on the first floor. Seven rooms have ensuite facilities. There are four lounge areas, a large dining room, a small visitors room and a central courtyard garden that has flowerbeds designed for colour and scent. Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was undertaken over a two day period, both visits were unannounced. During that time a number of residents, members of staff and the manager were spoken with. In addition a number of policies and procedures were examined and parts of the premises inspected. Prior to the visit surveys were sent to residents and staff assisted residents to complete these. A sample of relatives were also sent surveys and their views have also been incorporated into this report. Since the last key inspection the home has received an additional inspection carried out using the Short Observational Framework inspection, (SOFI). This system is used to assess the quality of life for people who have limited ability to express their views. The finding and subsequent requirements are detailed in a separate report and are available from the provider or upon specific request from the CSCI. The fees are currently £498.72. What the service does well: A comprehensive assessment is carried out before residents are offered a place in the home. Residents are able to spend a day in the home to meet with peers and staff before moving in. Residents can be assured that their privacy and dignity will be respected by people working in the home. Residents benefit from a wide range of appropriate activities. Residents benefit from staff supporting them to make choices about their daily lives. The provider ensures that staff receive appropriate safeguarding adult training which helps to protect people living in the home. Residents live in a clean home like environment and benefit from an ongoing programme of redecoration and refurbishment. Residents benefit for being cared for by suitably qualified and experienced staff in sufficient numbers to meet their needs. Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 6 Residents can be assured that the homes financial procedures protect their personal allowance. 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. Weybourne DS0000006862.V341056.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 Weybourne DS0000006862.V341056.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): 3,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents benefit from a comprehensive assessment which enables staff to assess they are able to meet peoples needs prior to them being admitted to the home. EVIDENCE: Following the SOFI inspection a requirement was made regarding the need for the homes Statement of Purpose to be updated to show what measures the home has put in place to meet the needs of people with dementia. Action has been taken to address this. Records were examined in relation to the assessment process for two people admitted to the home in recent months. It was evident that a comprehensive assessment has been completed by relevant health and social care professionals, in addition the manager stated she meets with all prospective residents prior to admission to assess whether staff are able to meet the Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 9 persons needs. Following the assessment the manager sends a letter to the prospective residents and their advocates advising them that following the assessment the home is able to meet their needs. Prospective residents are also given the opportunity to spend a day in the home to enable them to meet with staff and peers. The manager has put together a package of information which is given to prospective residents and their advocates this includes a copy of the homes Statement of Purpose detailing the care and services provided at Weybourne and other establishments managed by KCHT. All of the people who completed surveys stated they had been provided with sufficient information about the home before they moved in to enable them to make the decision that it was the right place for them. Weybourne does not provide an intermediate care service. Weybourne DS0000006862.V341056.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): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would benefit from more comprehensive care plans that provide staff with clear guidance on how to meet each persons needs. Residents can be assured that their privacy and dignity will be respected by people working in the home. Residents would benefit from improvements in medication procedures. EVIDENCE: Care plans were seen for three people. In general the documents were bulky and it was difficult to locate key information regarding the action required by staff to meet residents assessed needs. In one instance staff had completed a monitoring form in relation to inappropriate behaviour being exhibited by a resident however had not updated the record for the last three months. The manager stated that the resident was no longer exhibiting challenging behaviour and staff had forgotten to remove the documentation from the care plan. Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 11 Of the three care plans examined, one showed evidence of reviews taking place which included all relevant parties. The second care plan seen was for a person only recently admitted and the manager stated a review was due to take place shortly. The third care plan had been reviewed however this review had not been dated. Care reviews need to be dated to make sure they are carried out at appropriate time intervals and in order to be sure that the care provided continues to meet the residents needs. The manager stated KCHT had developed a new care plan format which was due to be introduced shortly following staff training. All of the people who completed surveys stated that they felt the home always or usually met the needs of their relative and kept them informed of important issues affecting their relatives life. Staff were seen to address residents by their preferred name and respected residents privacy and dignity when assisting with personal care. Staff knocked on bedroom doors before entering. A minority of residents became agitated when staff began assisting them to the dining room at lunchtime. Staff spoke to residents in a calm and reassuring manner. Records seen indicate that residents receive the health care support they require. The GP and district nurses attend residents in the home on a regular basis. A requirement was made at the time of the last inspection that the registered person must be able demonstrate staff have been directed to change the dose of medication prescribed to residents by their GP. It was evident that action has been taken to address this and the GP now signs any amendments on the MAR sheet. Medication records were examined in relation to two residents. A photograph is required for both people to reduce the risk of medication being administered in error. There is a record of medication received into the home and returned to the pharmacy for safe disposal. At present medication requiring refrigeration is stored in a domestic fridge and the temperature was slightly higher than that recommended. Discussion took place regarding purchasing a pharmaceutical fridge that would ensure medication was stored securely and at an appropriate temperature. Staff spoken with stated that they had attended the 12 week training course in relation to medication and its safe administration and had been assessed as competent to undertake this task. The room used to store medication would benefit from reorganisation as a number of items are being inappropriately stored in this area. The manager stated this issue would be addressed. Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 12 Other issues discussed with the manager included the need to have a medicine profile for each resident with evidence of regular medicine reviews. The need to have protocols in place for administration of ‘as required’ medicines such as pain relief for residents with poor or no communication skills. The need to evidence that staff responsible for medicine management are assessed annually as being competent to do so. Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 benefit from a wide range of appropriate activities. More information needs to be recorded with regards to the evening meal to ensure residents have a varied nutritious diet. Residents benefit from staff supporting them to make choices about their daily lives. EVIDENCE: Residents benefit from having three activity co-ordinators working in the home. One relative stated, I feel that my mums care home is fantastic. They always go out of their way for birthdays, Christmas Halloween etc. KCHT ran a competition at Christmas time for the best decorated home and this was won by Weybourne. One of the questions in the resident survey asks are there activities arranged by the home that you can take part in. All of the residents stated always one person stated they enjoyed music and singing. On one of the days I visited the home residents in the main lounge were enjoying a quiz. Staff responsible for arranging activities keep a detailed diary of who has participated in the events taking place. However this system does not highlight Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 14 if residents have enjoyed a particular activity or not which would be helpful for staff responsible for developing and reviewing care plans. Records seen for one resident indicate that he moved to England from Ireland a number of years ago. His care plan indicates that staff assist him to attend a local club for Irish people living in England, purchase Irish folk music CDs and attend the local church of his denomination. People who completed questionnaires stated they were always made to feel welcome and that staff were available to discuss issues regarding their relative. The majority of residents spoken with presented as relaxed and comfortable in the home. Staff were seen to promote residents autonomy and choice by encouraging them to choose refreshments, decide where they wanted to sit, which activities they wanted to participate in and which clothes they wished to wear etc. The majority of residents bedrooms are individually personalised with items of furniture from home pictures and photographs. Residents are provided with a choice of food at each mealtime this was displayed on a wipe board in the dining room. Meals are served in the main dinning room, however on one of the days I visited a resident who did not wish to come into the dining-room for lunch was provided with his meal in the reception area where he was sitting. Residents and relatives who completed surveys did not raise any concerns regarding the food provided. On the first day I was in Weybourne, kitchen staff served a hot dessert for all residents at the same time. Further, desserts were placed on the dining room table in front of people who were still eating their first course. This matter was discussed with the manager as in some instances peoples dessert would be cold before they could eat it and this practice also made lunchtime feel rushed. On the second day I was in the home a member of care staff was preparing the residents evening meal. This was a choice between sausage rolls with tinned tomatoes or assorted sandwiches. Discussion took place regarding the fact that assorted sandwiches on the menu is insufficient information to avoid repetition, particularly as sandwiches are served on a regular basis. In this instance the choice consisted of cheese or three different types of meat paste (although there was no way of differentiating by looking at them). More detailed recording was a recommendation made at the time of the last inspection and additionally the sandwich fillings should be reviewed with a view to providing more nutritious and appetising alternatives for residents choosing this option. Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. The provider ensures that staff receive appropriate safeguarding adult training which helps to protect people living in the home. The provider must improve record-keeping in relation to complaints brought to their attention so that people living in the home can be confident their concerns will be appropriately investigated. EVIDENCE: Information provided by the manager at the time of the visit indicated that four complaints had been received by KCHT. The logbook seen in the home recorded only two complaints. Record keeping in relation to complaints was unsatisfactory. For example in some instances there was details of complaints made but not the action taken to address them and in other instances there was information regarding the investigation but not details of the complaint. Further information in a copy of the providers audit highlighted a complaint had been made directly to KCHT head office however there was no information regarding the nature of the complaint or if subsequently an investigation was undertaken by the provider. All of the people who completed surveys stated they were aware of the home’s complaints procedure and a copy of this is included in the pack of information that the manager provides to prospective residents at the time of admission. Relatives who stated they had raised concerns with staff felt that appropriate Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 16 action had been taken to address their concerns and the matter resolved to their satisfaction. Since the last inspection one incident that occurred in the home has been investigated under the local authority protecting adults procedure. The provider liaised with social services in relation to the matter. The provider took satisfactory action in relation to the outcome of the social services investigation. There is evidence that staff understand the organisations whistleblowing policy and take appropriate action to raise any concerns they have regarding colleagues practice with relevant authorities. In addition staff attend local authority training courses regarding safeguarding adults. Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a clean home like environment and benefit from an ongoing programme of redecoration and refurbishment. EVIDENCE: The home continues to benefit from a redecoration and refurbishment programme. At the time of the last inspection a smell of urine pervaded the front reception area and a number of residents bedrooms. Action taken has eradicated the odour in the front reception area. The manager stated that where it is not been possible to resolve the issue in bedrooms and new carpets have been ordered. Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 18 On the first day of the visit the majority of residents were seated in one large lounge, chairs were side by side and two dining room chairs had been added to accommodate two new residents in the area. There was no room for tables for residents to put refreshments on and as described by a member of staff the lounge felt like a waiting room. This was discussed with the manager and by the time of the second visit some residents along with staff had been asked to move to another smaller lounge previously not used. Staff spoken with stated that the move has proved beneficial to all the residents involved and that both residents and staff enjoy the calmer more relaxed atmosphere with less people crowded together. Discussion took place with the manager regarding the possibility of purchasing small tables for both lounges as residents now hold their refreshments until finished and then place the cups under their chairs which could be potentially hazardous. A requirement was made at the time of the last inspection that the laundry should be upgraded to meet current health and safety requirements and action has been taken to address this. Staff responsible for undertaking laundry were spoken with and stated that the current equipment meets the needs of the residents accommodated. At the time of the last inspection a number of residents bedroom doors did not close effectively and it was unclear if doors recently replaced during the homes refurbishment programme met fire safety standards. The manager was asked to liaise with the fire authority and following this the provider took appropriate action to address this issue. Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from being cared for by suitably qualified and experienced staff in sufficient numbers to meet their needs. Further work is required to be able to demonstrate that sound recruitment procedures are in place to protect residents. EVIDENCE: On the day of the visit the staff rota was not an accurate reflection of staff working in the home. A member of staff was off work due to sickness and the rota had not been amended to reflect this. The manager stated that since the last inspection the number of carers on duty in the morning and afternoon has increased from four to five, in addition two senior staff also work shifts over a seven-day period. The rota indicates that the manager works Monday to Friday nine to five however she stated she routinely worked longer hours, for example starting work at 7 a.m. to meet with the night carers. The manager was advised to highlight this on the rota as the roster is not an accurate reflection of the hours that she works. Staff spoken with stated that it was not always possible to maintain the staffing levels at five carers however felt that this minimum staffing level was essential if residents were to continue benefiting from being cared for in the additional lounge. Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 20 A requirement was made at the time of the last inspection regarding the need for the home to hold records relating to the recruitment of staff in the home to ensure that the provider is able to demonstrate that sound recruitment procedures have been implemented. It was evident from the sample of four files examined that the manager had made considerable progress in compiling the necessary documentation for staff working in the home. For example there was evidence that CRB/POVA checks had been undertaken, references followed up and proof of identity checked as part of the recruitment process. However there was no photograph available for one member of staff recently appointed and for three of the four files examined no proof that staff been assessed as medically fit. Record seen indicated that staff had completed an induction programme when they commenced employment with KCHT. Everything in the induction was signed off by the member of staff and the person providing the induction. This induction is carried out on one day. Discussion took place with the manager regarding the need to prioritise areas that needed to be covered and to spread the induction over a few days to enable staff time to fully comprehend information. CSCI National Minimum Standards states that at least 50 of the staff working in the home must hold an NVQ two qualification in care. At present 75 of staff hold this qualification or above. At the time of the SOFI inspection a requirement was made regarding the need for staff to have specific training in relation to the caring and meeting the needs of people with dementia and action is being taken to address. All of the relatives who completed surveys stated they felt that staff working in the home had the right skills and experience to care for people living there. Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents continue to benefit from the changes the new manager has made in the home. Residents can be assured that the homes procedures protect their personal allowance. Action is required to protect residents and staff working in the home. EVIDENCE: A requirement was made at the time of the last inspection that the manager should submit an application to be registered with the CSCI. Action has been taken to address this. The manager holds appropriate qualifications and has a number of years experience working with older people. Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 22 The home presents as a relaxed, comfortable and friendly environment. Staff spoken with attributed this to enjoying their job and the fact that the majority of staff work together as a team. At the time of the first visit a freestanding electric heater was being used as an additional source of heating in one persons bedroom. The member of staff responsible for maintaining the building stated that there was an ongoing problem with the radiator, which he was still endeavouring to resolve. Discussion took place regarding the need for a risk assessment to be put in place in relation to the heater and that it be re-sited to a safer position within the room. Before the second visit took place the manager took action to purchase a heater that could be secured to the wall. A sample of records were examined in relation to residents personal allowance. Computer records are kept for money received and spent and receipts are obtained for all expenditures on resident behalf. The administrator manages this aspect of the service. Money being held on the behalf of residents tallied with records seen. A member of staff working in the kitchen recently sustained an injury from a faulty piece of equipment. The local Authority Environmental Health is currently investigating this issue. The manager stated that she would inform the CSCI of the outcome upon conclusion of the investigation. During the course of visits to the home staff were seen transporting residents in wheelchairs some of which did not have footplates. One person who completed a survey stated they were concerned that wheelchair footplates were not always in place when they visited their relative in the home. Action is required to address this issue to reduce the risk of residents sustaining injuries. Documents seen indicate that a KCHT do not routinely ensure that residents attending hospital are escorted by a member of staff. In the first instance relatives or friends are asked to undertake this task, however since the last inspection a resident was sent to attend a hospital appointment in an ambulance without being accompanied by either a relative or member of staff. Taking into account that Weybourne cares for people who have dementia this policy should be reviewed and made more flexible to reflect the needs of individual residents to ensure that as far as possible vulnerable people are supported and kept safe when attending appointments outside the home. From record seen at the time of the inspection regular maintenance and safety checks are undertaken to the fire detection system, electrical and gas appliances. The fire alarm sounded during the course of the visit and staff responded promptly and it was apparent that they knew what action to take in the event of an incident occurring. Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 23 From records seen staff have been provided with training in relation to moving and handling, food hygiene and health and safety. Records seen indicate that KCHT undertake regular audits of the care and service provided in the home and copies of these reports are forwarded to the CSCI. The organisation also arranges for an audit of their services to be undertaken by an outside body on an annual basis. Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 2 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 X X 2 Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP9 OP16 Regulation 13 22 Requirement Timescale for action 31/01/08 3. OP29 19 The registered person must ensure safe systems are in place to manage medicines. The registered person must 29/02/08 Maintain a record of all complaints received and action taken to address these. This information should be kept in the home and available for inspection. Staff records should contain the 03/03/08 documents as specified in Schedule 2 (Restated requirement - previous timescale 30/06/07 not met) The registered person must take further action to eradicate the smell of urine apparent in some areas of the home. Time scale 30/06/07 The registered person must ensure that the staff rota is an accurate reflection of staff working in the home. The registered person must ensure that footplates are used DS0000006862.V341056.R01.S.doc 3. OP19 16(2)(k) 29/02/08 4 OP27 27 29/02/08 5 OP38 13 31/01/08 Weybourne Version 5.2 Page 26 6 OP38 13 on all wheelchairs when staff are Transporting residents. The registered person must undertake a risk assessment in relation to sending residents unaccompanied to hospital. 29/02/08 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 OP9 Good Practice Recommendations The registered person should ensure a medicine profile is prepared for each resident. That there is evidence to show that residents medicines are regularly reviewed. that a protocol is prepared for the administration of ‘as required’ such as pain relief to residents with poor communication skills and evidence that staff responsible for medicine management have their competency assessed annually. It is recommended that a more detailed record of food is Kept to prevent repartition of food provided to residents and ensure that residents receive a balanced nutritious diet. The practice of serving residents desserts prior to them finishing their first course should cease, so residents receive (where appropriate) a warm dessert and mealtimes feel less rushed. Residents would benefit from the addition of small tables in lounge areas. 2. OP15 3 OP15 4 OP19 Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Weybourne DS0000006862.V341056.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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