Inspection on 02/11/06 for Wishmoor

This inspection was carried out on 2nd November 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

Wishmoor 01/08/07

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Wishmoor 21 Avenue Road Malvern Worcestershire WR14 3AY Lead Inspector Wendy Barrett Unannounced Inspection 09:40 2 November 2006 nd 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 Wishmoor DS0000065693.V320413.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. Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wishmoor Address 21 Avenue Road Malvern Worcestershire WR14 3AY 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) 01684 569162 Wishmoor Limited Mrs Mary Helena Douglas Care Home 19 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (19), of places Physical disability over 65 years of age (19) Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The home has a fit manager in post. Within 3 months of registration. A dedicated medication refrigerator must be available for medications to be kept at low temperature, and must be secure. Within 1 month of registration. A bound controlled drugs register must be kept. Wtihin 1 week of registration. A sluicing facility on the washing machine must be installed within 3 months of registration. Core training for all staff within first 6 months of registration; food hygiene, first aid at appointed level, moving and handling, infection control, fire and POVA training. The recommendations from the Environmental Health Officer are addressed. Within 1 month of registration. Radiators must be fixed to the wall. Within 1 week of registration. All pipe work in toilets and bedrooms must be covered and risk assessed. Risk assessment within 48 hours of registration and covered pipe work within 6 weeks of registration. A certificate of gas safety must be in place. Immediate on registration. Fire doors must close on rebates. Immediate on registration. 6. 7. 8. 9. 10. Date of last inspection Brief Description of the Service: Wishmoor is a detached house situated in a residential area of Malvern. It is close to community amenities. The home provides 19 places for older people who have personal care needs arising from general frailty of old age or physical disability. Six of the places can be used to accommodate older people who have care needs arising from dementia. The registered Provider is a limited company and a responsible individual maintains regular contact with the service on behalf of the Provider. A separate Care Manager is registered to manage the everyday care of residents. There are 15 single bedrooms and 2 double bedrooms. All these rooms are large enough to meet the National Minimum Standards’ space requirements. Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 5 No en-suite facilities are available. Information literature e.g. Service User Guide is available at the home and all new residents receive a copy. At November 2006 the fees ranged from £343-00p. to £389-00p. There are additional charges for newspapers, chiropody, dry cleaning and toiletries. Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This report has been written with reference to information held by the Commission about the service and that obtained during a visit to the service. Residents, relatives and professionals were sent survey forms so that their comments could also be taken into account. What the service does well: What has improved since the last inspection? The safety of the physical environment has been significantly improved since the new Provider was registered. There has also been a start on improving the overall quality of the accommodation. Progress made during the past few months is commendable as there was a great deal of investment needed when the home was taken over. The Provider has clear plans for future investment so that residents will have a high quality environment. Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 7 The staff are being encouraged to obtain a relevant qualification so that they can work safely and professionally with the residents. The Provider’s representative, a registered Care Manager and a deputy manager are working well together in overseeing all aspects of the service. There is an open approach to this work so that residents and their relatives are encouraged to participate in decision-making and can feel comfortable talking to staff about their concerns. The Provider readily consults other professionals and the Commission so that the best outcomes for residents can be achieved. When this identifies any shortfalls these receive prompt attention. Additional staff have been recruited to support the care staff in their work. What they could do better: The comments below indicate areas of development that should receive priority as part of the Provider’s commitment to continue improving the quality of the service. It is encouraging that the Provider has already committed time and resources to this end and has already identified future proposals. Medication management will be further strengthened through minor improvements to the recording systems. One or two comments arising from the inspection suggest that there may be a shortfall of staff at some times. This indicates a need to review the situation and this exercise should include consultation with residents, relatives and staff at the home. The current duty rotas need to show how adequate staffing is being achieved e.g. when a manager’s presence contributes to the minimum staffing level required this should be shown on the daily rotas. Although the Provider has already recognised the need for staff to receive training in adult protection, this should receive priority attention in any future training plans. Evidence in care records would be strengthened if there was more information about consultation with residents and relatives. There should also be more detail about social care that is provided for each resident. Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 8 There will soon be a new requirement for Providers to undertake selfassessment exercises and submit reports to the Commission. It would be advisable to await more details of this development before purchasing a separate quality monitoring system. 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. Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 9 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 Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 10 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): 1,2,3,4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are well managed because potential residents have plenty of information to help them decide if the home will be suitable. The staff also know about the new resident’s needs and preferences so they can help them to settle into the home in a way that suits them. EVIDENCE: There is up to date information literature that describes the service and what it can offer. Copies are available at the home and new residents all receive a copy. Contracts of Residence are provided and a resident survey form confirmed ‘annual increase was stated’. Two signed copies of contracts were seen at the home during the inspection visit. Senior staff at the home visit everyone before admission whenever possible. They gather as much information as possible about the potential resident’s needs and wishes and this is recorded for the staff to read. Examples of this work were seen at the home. Potential residents and their relatives are also Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 11 invited to look around the home and spend a little time with residents and staff. The assessment records addressed all the essential areas e.g. medication regimes, nutritional needs and preferences, mobility and continence issues. The record also referred to important aspects such as culture, religion and sexuality. The Provider intends to extend the assessment work to include more details about the individual’s social history and leisure interests. This information will be particularly helpful in respect of those residents who are unable to describe this to the staff once they arrive. The visitors’ book at the home indicated a regular flow of visitors to the home. Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive good attention to their health and personal care needs, with consideration of their wishes. Any risks or changes in condition are quickly identified. Involved health care professionals have confidence in the staff. EVIDENCE: Every resident has a written plan of care that is being regularly updated and reviewed by the staff. The resident had signed one of the sampled plans. It is important to include residents and/or their relatives in preparing and reviewing plans and efforts to do this should be more clearly shown in the records. Where there are potential risks identified e.g. falls, the staff undertake an assessment, using recognised assessment tools, and take action to try and reduce the risks e.g. a resident who had suffered several falls was referred to the G.P. for further investigation. The plans are being well written in that they are simple and precise so that staff know exactly how they should approach the care task for each resident. A relative commented – ‘I think they’re very Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 13 good – they communicate well. No bedsores, good diet’. An unsigned survey form referred to poor personal care but the anonymous nature of the comment made it impossible to pursue further. In this sort of situation it would be advisable to request an appointment with the Care Manager to discuss the concerns. There are separate records to record when a resident sees a health care professional. 4 G.P’s and a district nurse sent back survey forms that reflected confidence in the way staff deal with health care. Monthly reports written by the Provider’s representative contain examples of attention to residents’ comfort e.g. discussion about a resident’s difficulty in sleeping, the variety of meals offered. The deputy manager described satisfactory medication procedures at the home e.g. thorough recording of medication received, administered and disposed of. There are a few recommendations made at the end of this report that will further strengthen this area. The stock is securely stored in a temperaturecontrolled area and a dedicated fridge has been purchased. The care records include reference to self-administration and the deputy manager gave an example of the work done to maintain safety. A resident requested that staff leave her drugs with her to take later. An assessment identified a risk that, in this case, the drugs would not be sufficiently safe from other residents. The staff who are authorised to handle medication have received training. The Provider proposes to cover this again in the near future as some training was completed some time ago. An interviewed care assistant had been to two training courses run by Boots pharmacy. She described three practice observations by the Care Manager to ensure she was competent and she was also familiar with a medication policy and procedure at the home. A simplified version of this was displayed in the drugs storage cupboard for daily reference. Wishmoor DS0000065693.V320413.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There has been significant progress in offering residents choice and flexibility about the way they live although this approach to individual care planning should be more clearly shown in the relevant written records. Meals are hygienically prepared and attractively served by staff who understand about good nutrition and who provide alternative choices to suit individual preferences or dietary needs. EVIDENCE: Most of the resident responses to the Provider’s consultation exercise confirmed that the home provides suitable activities. None of the responses indicated a wish to be more involved in decision making at the home. Staff were observed singing and dancing with residents during the inspection visit. A musician was entertaining the residents during the afternoon. There were lots of smiles and chatting to suggest that the residents were enjoying this activity and felt comfortable with the staff. An activity programme is displayed in the dining room so residents can plan ahead. Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 15 A resident showed the Inspector some embroidered chair backs in the communal lounge where he was sitting. He was obviously very proud to know that his craftwork was being displayed and put to good use at the home. The Provider recognises that staff need more information about each resident’s life history so that they can appreciate the things that reflect the individuality of each person in their care. A new recording form has been produced – ‘getting to know you’ – and this is going to be completed (hopefully with the help of the residents and their relatives) when new residents are admitted. Although there were verbal examples given of staff spending one to one social time with residents e.g. taking them out for a walk, there should be a written record to show how the individual’s leisure interests are being supported. The managers would welcome more involvement from relatives in helping the residents enjoy a varied lifestyle although they felt that every effort is being made to encourage this. A relative commented – ‘Mary and ‘deputy’ are brilliant – ‘deputy’ goes to sit with Mum if she is distressed’. The cook was met during the inspection visit. She had only been in post for one week and was obviously still familiarising herself with her new job. She has previously obtained a catering qualification and was looking forward to practising her skills again. The menu of the day is advertised in the dining room. The cook gave an example of the choice offered to residents e.g. one resident enjoys highly flavoured meals and requests a sweet and sour dish most days. Special dietary needs e.g. there were 4 diabetic residents, are catered for and records kept of the food actually provided each day. Hygiene and safety systems were in place in the kitchen e.g. the Provider has implemented a ‘Safe Food Guide’ procedure recommended by the Environmental Health Officer. This includes procedures for checking food and storage temperatures, cleaning rotas etc. The kitchen had been deep cleaned the month prior to the inspection visit. It is planned to upgrade the kitchen once more essential work has been completed at the home. The dining room tables were very attractively presented in readiness for lunch – attractive tablecloths, table decorations, good quality crockery and cutlery, bowls of fresh fruit and a supply of cold drinks. The historical practice of using the dining room for storing and writing up care records is due to be reviewed by the new Provider. This will be welcomed, as it is not appropriate to use resident space for this purpose. Wishmoor DS0000065693.V320413.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives have good opportunities to talk about their concerns and they know who to talk to if they have a problem. They feel confident that the staff will listen to them and take any necessary action to put things right. The staff have information to help them make sure residents are safe and there are plans in place to strengthen this essential knowledge with more training. EVIDENCE: There is a written complaints procedure that is very well written to help residents and others raise any concerns they have about the service. Compliments are also encouraged so that there is a balanced view of the overall service. This information is included in the literature each new resident receives on admission. The Provider responded well to a concern raised with the Commission by an Environmental Health Officer. Action was promptly taken to stop staff entering the home through the kitchen. There is an open approach to management e.g. the management staff regularly consult residents about their views and suggestions e.g. the Provider Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 17 has recently asked the residents what type of bedroom flooring they would prefer – and intends to act on their suggestion even though this does not reflect her personal preference! There are policies and procedures implemented at the home that help staff identify potential abuse and tell them how to report any concerns they may have. Some staff have received training in adult protection as part of their National Vocational Qualification but there is a need to broaden awareness through the whole staff group. A care assistant knew that there were plans in place to provide this essential knowledge. Wishmoor DS0000065693.V320413.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been a substantial amount of work done this year to improve the safety of the residents’ accommodation and other facilities. The new Provider is aware of the remaining need for cosmetic refurbishment and has firm plans to deal with this in a reasonable timeframe. EVIDENCE: The physical environment needed a lot of work to achieve a satisfactory quality when the new Provider purchased the home. The amount of investment and time taken to deal with this is commendable. Much of the work has appropriately been focused on safety aspects and may not be immediately evident e.g. new emergency lighting throughout the building, covering of heated surfaces. Work identified by the Environmental Health Officer has been completed e.g. re-tiling of kitchen. The safety of the water supply has been Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 19 strengthened with the fitting of a new thermostat and a legionella check had been completed the week prior to this inspection visit. Two new washing machines and a tumble drier have been supplied following consultation with the Public Health Protection Unit. Sometimes, additional work has been identified e.g. having to replace floorboards. The home is now much safer for the residents e.g. handrails have been fitted throughout the building. The cosmetic improvement of the environment is now starting to be addressed and the Provider has a structured plan to achieve a high quality of accommodation as soon as possible. This will, of course, take time because there is so much to do, but there has already been some investment in this direction e.g. some new bedroom furniture suites, replacement carpets, redecoration in various areas and new curtains etc. Wishmoor DS0000065693.V320413.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are generally enough staff on duty to care for the residents but there are some indicators that this may not always be the case. New staff are carefully selected to be sure they are suitable to work with vulnerable adults. Once appointed they receive the training they need to work safely with the residents. EVIDENCE: The new Provider has employed more staff to support the care assistants e.g. cleaner, handyman. The Commission has also been consulted about a suitable formula for working out how many staff are needed to cope with the varying dependencies of the resident group. There were enough staff at work at the time of the inspection visit and two care assistants confirmed that this was the usual level of staff at work. They felt the evening periods could be quite busy for the care assistants but there are inevitably times of high activity in any home e.g. helping residents to get up or go to bed. These busy periods will need to be monitored. A resident survey form referred to ‘busy’ staff and one relative’s survey form questioned whether there were always enough staff on duty. The Commission has received an anonymous contact from a relative that describes concern about the level of staffing and the competence of some staff who are left in charge It is, therefore, encouraging that the Provider is already Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 21 looking at the staffing arrangements and has already increased the previous staffing complement. The duty rotas indicated two care assistants at work during afternoon periods. This raises the question of their ability to prepare and serve tea without having to mix this work with care demands. The Provider’s representative and the Care Manager explained that there is always at least one of the managers present to help at tea time although this is not recorded on the duty rota. The presence of a third person during all meal periods should now be recorded for each day of the week. It is very important to be sure that whoever is working in the kitchen should not have to come out into the home to help with care tasks while they are preparing meals. There has been a reduction in the number of qualified staff due to the recent loss of a few staff who had already achieved a National Vocational Qualification (NVQ). The Provider is encouraging more staff to work towards this award and an interviewed care assistant mentioned that she was being supported through her N.V.Q level 3, having already achieved her level 2 award. During this year staff have received essential health and safety training e.g. inhouse fire safety instruction and fire drill practice. A pre-inspection questionnaire also lists food hygiene, first aid, moving and handling and infection control. The Provider proposes to arrange refresher medication and abuse awareness training in the near future. These are very important areas to ensure the safety of residents and need to be given priority within future training programmes. Reports from the Provider’s representative refer to careful recruitment practice i.e. checking identity documents for staff applicants and also receipt of Criminal Records Bureau and Protection of Vulnerable Adults’ register checks. The recently appointed cook confirmed that references had been sought and checks made before she was offered a job. . Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33,35, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are benefiting from a management team who know what their responsibilities are and who are prepared to spend the money and effort on ensuring the quality of the service will continue to improve. EVIDENCE: The Provider has only taken over the service in the past few months. This change of ownership meant that the new Provider had to satisfy the Commission of their fitness to be registered and was successful in doing this. The existing registered Care Manager had an extended period of sick leave at about the same time as the change of ownership. This is why there was a condition linked to the new registration requiring the Provider to make sure there was a fit Care Manager in post within a given timescale. Happily, the Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 23 original Care Manager has been able to resume her duties and continues as the registered Care Manager. The relevant condition of registration can, therefore, now be removed. The Care Manager is supported with her work through the regular involvement of the Provider’s representative at the home, and an experienced deputy manager. There is a clear division of the areas of work each of these managers oversee and this means that the home is run in an organised, transparent way e.g. the Deputy Manager deals with the management of medication procedures. Since being registered, the Provider has undertaken two consultation exercises with residents and relatives. A summary report of the findings of the most recent exercise was given to the Inspector during the inspection visit. This reflected satisfaction with the service being offered. New curtains and a review of the menus, including a second lunchtime choice, were identified as action required following the consultation. There has also been work to identify a suitable formal system of quality monitoring the service. Literature relating to this exercise was seen at the home. New policies and procedures were implemented in October 2006 to protect the residents’ personal money and property. Relatives support residents who are unable to manage their own financial affairs but there is a petty cash resource for residents who need small amounts of cash for personal spending. Records are kept to show how this is managed safely on behalf of each individual. The Commission is being kept appropriately informed of events occurring at the home that affect the welfare of the residents e.g. falls. The Provider’s representative has also been submitting reports to show how the service is being monitored and improved. There was a lot of work needed to improve the quality of the physical environment when the new registration was approved. It has been necessary to deal with health and safety aspects first and the Provider has worked closely with other professionals e.g. Fire Safety Officer, Environmental Health Officer. Infection control measures have been addressed through consultation with the Public Health Protection Unit. Staff have received essential health and safety training from the new Provider e.g. a care assistant said how pleased she was to have been able to receive training in fire safety, first aid, health and safety and infection control. A recently recruited cook was aware that the Care Manager was already arranging for her to receive refresher food hygiene training. Wishmoor DS0000065693.V320413.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 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x 3 x 3 3 Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement Timescale for action 30/11/06 2 3 OP9 OP27 13(2) 18(1)a 4 OP27 18(1)a When medication is prescribed ‘as required’ there must be written instruction to help staff define the point at which the medication should be administered. Allergy boxes must always be 30/11/06 completed on administration record sheets. There must be a minimum of two 30/11/06 care staff on duty during all tea time periods with a third staff member employed to prepare and serve the meal. This must be confirmed on duty rotas kept at the home. The adequacy of current staffing 31/12/06 arrangements must be confirmed through a review exercise that includes consultation with staff, residents and relatives. The outcome of this exercise will contribute to the Provider’s overall self-assessment of the service. Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP7 OP12 Good Practice Recommendations There should be more written evidence of consultation with residents and/or their relatives in preparing and reviewing plans of care. There should be a record of individual and group social opportunities offered to each resident based on social care assessment and plan of care. All staff should receive instruction in adult protection awareness as a priority in future training plans. The Provider is advised to consider the imminent introduction of Annual Quality Assurance Assessments and what these will involve before purchasing a formal quality monitoring system for the home. Information is available on the CSCI website. OP18 OP33 Wishmoor DS0000065693.V320413.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Wishmoor DS0000065693.V320413.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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