Inspection on 08/06/06 for Whiteley Village Care Centre

This inspection was carried out on 8th June 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Whiteley Village Care Centre 27/11/08

Whiteley Village Care Centre 10/12/07

Whiteley Village Care Centre 04/10/05

Whiteley Village Care Centre 20/06/05

Whiteley Village Care Centre 06/01/05

Whiteley Village Care Centre 10/08/04

Whiteley Village Care Centre 24/02/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Whiteley Village Care Centre Whiteley Village Care Centre Whiteley Village Walton On Thames Surrey KT12 4EH Lead Inspector Lisa Johnson Unannounced Inspection 8th June 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Whiteley Village Care Centre DS0000017658.V299076.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. Whiteley Village Care Centre DS0000017658.V299076.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whiteley Village Care Centre Address Whiteley Village Care Centre Whiteley Village Walton On Thames Surrey KT12 4EH 01932 825831 01932 825843 sister@whiteleyvillage.org.uk 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) The Whiteley Homes Trust Mrs Nancy Hunter Care Home 114 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (114) of places Whiteley Village Care Centre DS0000017658.V299076.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 58 beds providing nursing care for older people from the age of 60 years Of the 114 older people accommodated, Up to 4 may be in the category DE(E), older people suffering from dementia 4th October 2005 Date of last inspection Brief Description of the Service: Whiteley Care Centre is located in Whiteley Village near Walton on Thames, Surrey. The village and care services are owned and operated by the charitable homes Whiteley Homes Trust. The village is self-contained with amenities, sports and social activities provided on site. Whiteley house provides personal support and nursing care, which is provided on the ground and first floor. The Care Centre also provides personal support to 28 people in Ingram house, which is based next to the main building. The weekly charges for the care centre are £650-£950 per week. Ingram House starts from £550 per week. Whiteley Village Care Centre DS0000017658.V299076.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first key inspection carried out in 2006/2007.The unannounced inspection took place over eight hours and was carried out by three inspectors, Mrs. L Johnson, Mrs. L Garrett and Mr. D Ramdas. Mrs. N. Hunter the registered manager represented the establishment. A full tour of the premises was undertaken and care plans, staff files and policies and procedures were sampled. The inspectors spoke to twelve service users and eight members of staff. A number of comment cards were sent to service users and relatives to obtain their views on the service provided. The responses received are included in this report. The inspectors would like to thank the service users, relatives and staff for their hospitality and cooperation during this inspection. What the service does well: The home was open, and friendly. Staff were observed to be talking to service users with respect and service users were observed to be relaxed in their company. Staff were observed to be knocking on service users doors and shutting doors when carrying out personal care respecting individuals privacy. A number of individuals spoken to were happy about the care they were receiving. Comments included “Everybody tries to make you happy”. “It’s a marvellous place and I would recommend it”. “Staff are very good and I get all the care I need”. The home offers a range of recreational and leisure activities and during the inspection a coffee morning and residents meeting was taking place. The day care coordinator was observed to be motivated and enthusiastic. One individual stated, “ I like the activities lady, she really tries hard for us”. Service users bedrooms were homely and individualised in appearance with evidence that service users had a range of personal furniture and belongings on display, which met individual’s interests and preferences. Whiteley Village Care Centre DS0000017658.V299076.R01.S.doc Version 5.2 Page 6 The home was pleasant, clean and hygienic and the home has gained a food hygiene gold award. Choices of meals were provided which were well presented and nutritious with the catering manager visiting each unit weekly to discuss dietary arrangements and to gain feedback from service users. Six service users spoken to expressed their satisfaction with the meals provided. Eight comment cards received conclude that service users are happy with the care they receive. One individual living in Ingram House stated, “We are all well cared for by the staff. We have a pleasant dining room for meals and a comfortable sitting room to share with other residents and we are all cared for medically”. Another comment received was “We have a large airy sitting room where we can entertain and a great sense of freedom by being able to go out daily”. The staff are ever friendly and helpful”. What has improved since the last inspection? What they could do better: A requirement was made that the presentation of care plans and daily records is reviewed as some of the documents had been photocopied over a period of time and the daily records were recorded in boxes making them difficult to read. Some areas in the home were identified as needing repainting. Evidence was seen that the service has a maintenance and reniewal programme; however a copy was not provided. it was required that the registered manager provides a copy to the Commission for Social Care Inspection. A further requirement was made that a broken bed rail is repaired in one bedroom and it has been Whiteley Village Care Centre DS0000017658.V299076.R01.S.doc Version 5.2 Page 7 confirmed since the site visit that this has now been repaired. This is to ensure that service users have a comfortable and well-maintained home to live in. The Inspectors noted that one of the dining room tables due to its design was difficult for people using wheelchairs to sit comfortably at the table. A requirement was made that this dining room table is changed to meet the needs of the service users. Some service users stated that there are delays in staff responding to the call bells and the inspectors noted the high dependency of service users. A requirement was made that the registered manager reviews the present staffing levels based on the residential forum and to provide the outcome to the Commission for Social Care Inspection. This is to ensure that the service is able to provide the appropriate numbers of staff to meet the assessed needs of individuals. Six staff personal files were sampled and some items were missing from some individual’s files including a photograph and gaps in the employment history for one person. It was also noted that that reference requests were tick boxes and did not contain enough detail. A requirement was made that these items are obtained and provided in individual’s files. This is to ensure that service users are protected by the homes recruitment policies and procedures. The service provides training in emergency first aid for staff. However a requirement was made that professionally trained staff need to keep up to date with emergency first aid training to ensure that they are trained and competent to meet the needs of service users in an emergency. At the previous inspection a requirement was made that doors should not be wedged open. The registered manager followed up this issue and made contact with the fire officer who visited the home, however no clear written clarification was provided. The use of door wedges was found again during this inspection and a fire officer has attended the home and provided a written report to the registered manager and the Commission for Social Care Inspection, which concludes that the home needs only to provide automatic door devices to be fitted to the self-closing fire doors in the corridor. 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. Whiteley Village Care Centre DS0000017658.V299076.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 Whiteley Village Care Centre DS0000017658.V299076.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that service users and their relatives are provided with adequate information so that they are able to make an informed choice about the suitability of the home as a place to live. The home is able to demonstrate that pre admission assessments are completed prior to admission to the home. Each service user is provided with written contract/statement terms and conditions with the home. The home does not support service users for intermediate care. EVIDENCE: The home has produced a statement of purpose and service user guide detailing the aims and objectives and services that the home is able to offer. Copies of service user guides were observed in some individual’s bedrooms. The inspector spoke to one individual who had recently moved in to the home who said, “I recall being given some information and this was discussed with my relative”. Whiteley Village Care Centre DS0000017658.V299076.R01.S.doc Version 5.2 Page 10 Pre-admission assessments were completed which were sampled and were detailed and comprehensive. Two contracts were sampled which detailed the terms and conditions with the home and extra charges explained. Contracts sampled were signed by the individual or their representative. Whiteley Village Care Centre DS0000017658.V299076.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user is provided with an individual care plan, which details that individual’s health, personal, emotional and social needs are met. Service users and/or their representatives sign their plans where possible to ensure that they are fully involved in the process. Improvement is needed in the presentation of care plans and daily notes. Service users are protected by the homes medication policy and procedures. Service users privacy and dignity is respected. The home is able to demonstrate that individual’s wishes concerning illness and death are respected. EVIDENCE: Eight care plans and daily records were sampled which were detailed and comprehensive with monthly reviews being completed. Evidence was seen that detailed risk assessments were completed including for example tissue viability, nutrition and mobility. Records were maintained of any falls incurred by individuals and referrals are made to a falls clinic if required. The home also monitors and audits the incidences of falls. Guidance is in place for MRSA that is made known to staff. However a requirement was made that the Whiteley Village Care Centre DS0000017658.V299076.R01.S.doc Version 5.2 Page 12 presentation of care plans and daily records are reviewed as some of the documents had been photocopied over a period of time and the daily records were recorded in boxes making them difficult to read. Service users are supported to have access to a range of specialist services. During the inspection a number of health professionals were seen visiting including the physiotherapist, dietician, speech therapist, tissue viability nurse and the GP. One individual stated “ We are well looked after medically”. The homes medication administration systems were examined and records were maintained adequately. A list is maintained of staff authorised to administer medication and photographs of individuals were available with their medication card. Medicines were stored appropriately including the controlled drugs kept in the home. A recent medication audit has been completed and the local pharmacist visits every six months with the medication administration procedures having been recently reviewed and updated. Staff receive training and assessments in the administration of medication and registered nurses receive training updates on syringe drivers. However it was recommended that any medication that is transcribed on the medication card by staff this should be checked and signed by two staff. Staff were observed to be shutting bedroom and bathroom doors while carrying out personal care with individuals and were seen to be talking to service users respectfully. Screening was in place in double rooms to maintain privacy. A number of individuals call bells were placed near to individuals for them to be able call assistance when required. Eight comment cards received confirm that service users feel that their privacy is respected. The home has a death and care of the dying policy and a resuscitation policy McMillan nurses and Princess Alice hospice support the home when requested. Whiteley Village Care Centre DS0000017658.V299076.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that service users have access to a range of recreational and leisure activities and maintain links with their family/friends and the local community. Service users are supported to make choices and individual preferences are respected. Service users receive well-presented and balanced meals. EVIDENCE: Information on activities provided was displayed and advertised around the home. An activities coordinator is in post and during the inspection a coffee morning and residents meeting was taking place. The day care coordinator was observed to be motivated and enthusiastic. One individual stated, “ I like the activities lady, she really tries hard for us”. A hairdresser visits the home and a mobile library was seen visiting during the inspection. The home also holds sherry mornings and aromatherapy and one individual told the inspector he was going to the local club within the grounds to play pitch and put. Other activities include for example keep fit, concerts, art and gardening clubs and a range of facilities that the village offers. A comment card received from one individual states, “There is great sense of freedom by being able to out going out daily”. Whiteley Village Care Centre DS0000017658.V299076.R01.S.doc Version 5.2 Page 14 Relatives and friends can visit without restrictions and are able to visit in private. Two comment cards received from relatives conclude that they are able to visit their relative in private and are made to feel welcome when visiting the home. One service user said she had a key to her room and wall safes were observed in some rooms. Two individuals spoken to choose to go out for walks in the local grounds and use the facilities, which the village provides. Service users are able to bring their own possessions in the home, which were seen, on display in bedrooms. Individuals are provided with a choice of meals and alternatives are offered if the meal is not to their preference. The catering manager visits each unit weekly to discuss dietary requirements with service users and staff, which was evidenced during the inspection. The lunchtime meal was appealing and presented to a good standard including well-presented trays for individuals receiving meals in their rooms. Whiteley Village Care Centre DS0000017658.V299076.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives have access to an effective complaints procedure and their views are listened to and acted upon. Policies and procedures are in place, which protects service users from abuse. EVIDENCE: The home provides a complaints procedure, which was seen on display through the home. Four copies of complaints have been received by the Commission for Social Care Inspection that have been fully investigated within agreed timescales up by the registered manager following the homes complaints policy and procedures. A number of positive comments were received by the inspectors about the care they were receiving. Comments included “Everybody tries to make you happy”. “It’s a marvellous place and I would recommend it”. “Staff are very good and I get all the care I need”. Eight comment cards received from service users reflect that they that they feel safe in the home and would know who to speak to if they had any concerns. Two relatives confirm they are aware of the homes complaints procedure and are kept informed of important matters concerning their relative Four issues have been referred following the local authority safeguarding adult’s policies and procedures. Safeguarding adult policies and procedures were present in the home and staff training records were sampled which concluded that staff are receiving adequate training. Whiteley Village Care Centre DS0000017658.V299076.R01.S.doc Version 5.2 Page 16 Whiteley Village Care Centre DS0000017658.V299076.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 23 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well maintained with some minor redecoration needed in some areas. Service users bedrooms were viewed as comfortable. The home is able to demonstrate that service users are provided with specialist equipment but needs to review the suitability of the dining room tables. The home is clean and hygienic ensuring that service users have a pleasant home to live in. EVIDENCE: The home is spacious and well maintained. There are extensive, well maintained grounds for service users to access. However the inspector noted that there was some repainting required in the main building. The home has a written programme for refurbishment and maintenance. The inspectors saw evidence that a programme was in place, however a copy of the programme was not provided. A requirement was made that a copy of the maintenance Whiteley Village Care Centre DS0000017658.V299076.R01.S.doc Version 5.2 Page 18 and fabric renewal programme is provided to the Commission for Social Care Inspection. One individual stated, “The grounds are lovely”. Two written comments received from service users confirm, “ We live in a well cared for building, surrounded by beautiful grounds” and “We have a pleasant dining room for meals and a comfortable sitting room”. The home provides a range of specialist equipment to ensure that residents independence is maximised including assisted baths, grab rails, seat raisers, hoists, pressure relieving mattresses, cushions and nurse-call bells which has a print out system that can be monitored. One of the dining room tables due to its design was difficult for people using wheelchairs to sit comfortably at the table. A requirement was made that this dining room table is changed to meet the needs of the service users. Bedrooms in all units were spacious, pleasant and comfortable. It was pleasing to see individuals having a range of their personal possessions and furniture in their bedrooms. One individual enjoys painting and showed the inspector her display and another person had a three-piece suite in his room. The home was cleaned to a good standard and was hygienic. Laundry facilities are provided in a separate facility within the grounds of the village. Infection control procedures were in place and appropriate hand washing materials were provided in all bathrooms and toilets. The kitchen was clean and hygienic and the home has obtained a gold food hygiene award. Whiteley Village Care Centre DS0000017658.V299076.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 at least once during a 12 month period. 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. The numbers of staff on duty was not adequate to fully meet the needs of service users. On the whole service users were in the safe hands of the staff who were competent and trained to do their jobs. EVIDENCE: Each unit has their own staff team. Each unit is headed by a manager or a registered nurse. There are forty-eight beds on the second floor-nursing unit, which provides support to highly dependent individuals. During the inspection there was the nursing home manager, two registered nurses and ten care assistants. On the ground floor, which consists of residential beds and ten nursing beds there was one qualified nurse and six carers. In Ingram house there are twenty-seven beds and five members of staff were on duty. The home also provides ancillary staff. The home has four care worker vacancies and the registered manager informed the inspector that new staff have been recruited and will be commencing shortly. The home uses some agency, one individual spoken to said that he was provided with an induction and that the home tries to ensure that he works with the same group of service users to maintain consistency. However during the inspection the home was very busy and a number of calls were being received with evidence that staff were attempting to respond as promptly as possible. Four-service users spoken to Whiteley Village Care Centre DS0000017658.V299076.R01.S.doc Version 5.2 Page 20 state that there are delays at times with response times. A requirement was made that the registered manager should review the present staffing levels based on the residential forum to ensure that the appropriate numbers of staff is sufficient and supports the assessed needs of service users Fifty percent of care staff have obtained National Vocational Qualifications (level 2 or above. Three members of staff spoken to confirmed that they had completed National Vocational qualifications Five staff personal records were sampled POVA first checks and police checks are completed for new staff. However one individuals work history had some gaps in it. The inspectors discussed with the manager that the reference form should be reviewed as the present form consists of tick boxes and more detail is required. It was required that that this information is acquired to ensure that service users are protected by the homes recruitment policies and practices. A training schedule is maintained and the inspectors spoken to the trusts training coordinator. A wide range of training is provided and Individual training records are maintained for all individuals. Induction training is provided which is linked to skills for care and mandatory training is conducted including safeguarding adults, moving and handling. Fire safety, food hygiene, health and safety and infection control. Bereavement training and external training and conferences can be arranged through the training coordinator. All staff receive first aid training one day and four-day courses with thirty-eight staff hold current first aid certificates. One member of staff spoken to felt that she felt supported and was able to provide evidence of training that she had completed. However a requirement was made that professionally qualified staff need to remain up to date with their emergency first aid training to ensure that staff have the appropriate skills and competencies to meet the needs of service users. Whiteley Village Care Centre DS0000017658.V299076.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is able to demonstrate that she has the appropriate qualifications and experience to manage the home and has implemented quality assurance systems. One item should be actioned. The home is able to demonstrate that the financial interests of service users are protected. Staff receive formal supervision. The health, welfare and safety of service users are protected and the home is run in their best interests. EVIDENCE: The manager is a qualified nurse and holds the Registered Managers Award and has the appropriate skills and experience to manage the home. During the inspection she was seen to be visiting units in the home and one staff member stated that the manager is “approachable and listens”. Whiteley Village Care Centre DS0000017658.V299076.R01.S.doc Version 5.2 Page 22 Quality assurance systems are in place and service users and relative’s feedback forms have been recently updated. During the inspection a residents meeting was held which was advertised on notice boards. One service user spoken to felt that these meetings were beneficial and any issues raised are followed up. The responsible individual completes monthly quality visits and copies of the reports are provided to the Commission for Social Care Inspection. Monies held on behalf of service users were sampled purchases and balances were recorded. Balances were checked for three individuals, which were correct with all monies being maintained in a secured safe. A number of health and safety procedures were in place. Policies and procures have been updated; however a requirement was made that these should be dated. Substances hazardous to health (COSHH) were stored securely and appropriately. Accident records and records of incidents were maintained. Examination of records and certificates identified systems are in place for routine service and maintenance arrangements for the environment. At the previous inspection a requirement was made that doors should not be wedged open. The registered manager responded and made contact with the fire officer who visited the home, however no clear written clarification was provided. The use of door wedges was found again during this inspection and a fire officer has since attended the home and provided a written report to the registered manager and the Commission for Social Care Inspection, which concludes that the home should provide automatic door devices to be fitted to self-closing fire doors only in the corridor. Whiteley Village Care Centre DS0000017658.V299076.R01.S.doc Version 5.2 Page 23 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 2 3 X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 X X 2 Whiteley Village Care Centre DS0000017658.V299076.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement Timescale for action 08/08/06 2 OP19 23(2)(d) The registered person must ensure that the presentation of care plans and daily records is reviewed. a) A copy of the programme 08/07/06 of routine maintenance must be provided to the Commission for Social Care Inspection b) One bed rail must be repaired. The registered persons must ensure that the design of one dining room table is changed to meet the needs of the service users. The registered person must review the present staffing levels provided in the home based on the residential forum with the outcome to be submitted to the Commission for Social Care Inspection. The registered person must ensure that the work history for all new staff applicants is fully completed and that all required DS0000017658.V299076.R01.S.doc 3 OP22 23(2)(a) 08/08/06 4 OP31 18(1)(a) 08/08/06 5 OP29 19 (Schedule 2) 08/07/06 Whiteley Village Care Centre Version 5.2 Page 25 6 OP30 18(1)(c) (1) 7 OP33 17(3)(a) 8 OP38 23(4)(a) (c) (1) documents are available on individual files. The registered person must ensure that all professionally qualified staff remain up-to-date with their emergency first aid training. The registered person must ensure that all policies and procedures are dated when they are reviewed. The registered persons must fit automatic door release devices to self-closing fire doors in the corridor. 08/08/06 08/08/06 08/07/06 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 Refer to Standard OP9 Good Practice Recommendations It is recommended that when medication is handwritten on the medication administration card this is checked and signed by two staff. Whiteley Village Care Centre DS0000017658.V299076.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 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 Whiteley Village Care Centre DS0000017658.V299076.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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