Inspection on 22/11/05 for Withy Grove Care Home

This inspection was carried out on 22nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Withy Grove Care Home 29/09/08

Withy Grove Care Home 29/07/08

Withy Grove Care Home 08/08/07

Withy Grove Care Home 28/11/06

Withy Grove Care Home 26/05/06

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

CARE HOMES FOR OLDER PEOPLE Withy Grove Care Home Withy Grove House Off Poplar Grove Bamber Bridge Preston Lancashire PR5 6RE Lead Inspector Pauline Randles Announced Inspection 22nd November 2005 09:10 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 Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 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. Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Withy Grove Care Home Address Withy Grove House Off Poplar Grove Bamber Bridge Preston Lancashire PR5 6RE 01772 337105 01772 620158 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) Ashbourne (Eton) Limited Care Home 54 Category(ies) of Dementia (24), Old age, not falling within any registration, with number other category (30) of places Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 54 service users to include: Up to 24 service users in the category of DE - (Dementia). Up to 30 service users in the category of OP - (Old Age, not falling within any other category). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 4/5/05 2. 3. Date of last inspection Brief Description of the Service: Withy Grove House is a residential care home providing 24-hour personal care and accommodation for 30 older people who have care needs and 24 older people who have care needs associated with dementia. The proprietors of Withy Grove House are Ashbourne Healthcare Limited. Withy Grove House is a converted Manor House, which is set in its own landscaped gardens adjacent to parkland. The home is in a predominantly residential area, but within easy walking distance of Bamber Bridge centre. Bus and train services can be accessed to larger towns, such as Preston, Chorley and Blackburn. Bedroom accommodation is on the ground and first floors. All bedrooms are used for single accommodation and 29 have en-suite facilities. There is a passenger lift. Accessible toilets and bathrooms are located on both floors near to bedroom and living rooms. There are sitting and dining areas sited on both floors and across the car park from the home is a private lawn area where residents are able to enjoy activities, weather permitting. Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over a six and a half hour period. This was the first inspection since the appointment of the new manager. During the course of the inspection four residents, two senior staff members, three care staff, the cook, the activities organiser and a relative were spoken to. In addition policies, procedures and records were examined and areas of the premises related to the focus of the inspection were viewed. Stephanie West, Pharmacy Inspector, was also present at the inspection and undertook a review of medication procedures and practices. The findings from the review have been incorporated in this report. Pre inspection information, including comment cards and a letter from a relative, contributed to the findings. What the service does well: What has improved since the last inspection? Improvements to the environment had continued and these had made a significant impact particularly in relation to the private and communal areas used by residents. The homes assessment, care planning and risk assessment processes had been improved to ensure that the needs of the residents were identified and met. Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 Page 6 Communication with the relatives of residents had improved. There was evidence of recent consultation with relatives that was ensuring sufficient relevant information was known in regard to personal needs and preferences. Residents and their relatives, or representatives, had been invited to contribute to the care planning and review processes as previously requested. One relative had written to say “the home is definitely on the way up since Ashbourne took over earlier in the year.” Staff members were paying greater attention to the personal hygiene needs and appearance of residents. A dedicated activities organiser had introduced a comprehensive activities programme to meet individual and group needs. The staff recruitment procedure had been effectively developed to ensure the protection of residents. Recent training for example, dementia awareness had made a noticeable difference to staff development and competence. What they could do better: Employment practices must be improved to ensure that contracts of employment are issued to all staff so that terms and conditions of employment are known, understood and agreed. To reduce the potential for inappropriate restraint or physical injury risk assessments relating to bed rails must be undertaken using a suitable format involving the resident, their representatives and district nursing services. The pre admission process must include written confirmation of whether or not a residential place can be offered so that prospective residents are clear about the assessment outcome. Medication practices need some improvement to reflect good practice requirements and protect the health of residents. A summary of the analysis of recent accidents and incidents involving residents should be undertaken to identify any common themes emerging. A copy of the analysis and findings to be forwarded to the Commission for Social Care Inspection by mid December as agreed. To evidence the inclusion of residents, activity records should be developed to note consultation and participation that had taken place and satisfaction levels. To ensure the validity of records the kitchen cleaning schedules and the maintenance action plan should be fully completed at all times. In order to improve accountability procedures should be kept up to date and the system for staff to sign when read and understood should be maintained. It should be clear that procedures of Withy Grove House are care procedures Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 Page 7 and that all records refer to care services and care hours not nursing hours to avoid any misconceptions that might occur. Training relating to care of the dying should be sourced to develop skills and knowledge in this area. Supervision should occur at least six times a year so that staff members receive appropriate support and guidance. To ensure maximum safety of the premises evidence of compliance with the Water Fittings Regulations 1999 should be sought. Care plans and the reviews should be signed by the resident or their representative to confirm their involvement. At least 50 of care staff should achieve NVQ 2 by the end of December 05 to maintain skills and competence. Also, the home’s manager must complete the procedure to become registered manager of Withy Grove House and register for NVQ Level 4 in management without delay to ensure future management accountability. 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. Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 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 Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 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 and 3 The Statement of Purpose and Service User Guide provided prospective residents and their representatives with full details of the home’s services and facilities enabling an informed choice to be made about residency. Pre admission needs assessments were thorough and enabled an informed decision to be made as to whether a residential place could be offered. The process for confirming whether a residential place is to be offered was inadequate at present. EVIDENCE: The Statement of Purpose and Service User Guide had been reviewed to reflect recent changes in ownership and management. All relevant aspects of the home’s services and facilities were reflected in the content as required. A copy of the revised Statement of Purpose was available by the front door of the care home. Revised Service User Guides were in the process of being issued to residents. A copy of the last inspection report was also available in the hallway. Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 Page 10 The pre admission assessment format is thorough and comprehensively covers all aspects of potential service need. The most recent assessment related to a resident on respite stay and had been adequately completed. Prospective residents were being advised verbally whether a residential place was to be offered. To fully meet regulatory requirements the confirmation must be in writing. Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 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 and 11 Care planning procedures effectively guided care practice and ensured an appropriate response to identified need. Risk assessment processes did not fully address the potential for entrapment or physical injury that could be caused through installation of bed rails. The manager has a good understanding of the areas in which the handling of medication needs to improve. There were plans being developed to ensure improvements are implemented. The rights of residents to be treated with dignity and respect were upheld by the procedures and practices within the care home. Staff knowledge and skills could be suitably developed through participation in specialist training relating to care of the dying. EVIDENCE: Care plan records examined were detailed, up to date and were used to actively guide care practice on a daily basis. When asked about care services Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 Page 12 provided, residents said, for example, care staff members are “kind” and “good.” A relative had written to thank the staff for “taking such great care of my mother.” It was confirmed, in discussion with a resident, that she had knowledge of her care plan but had not been asked to sign it. The manager confirmed that steps were being taken to improve involvement of residents and include relatives in care plan reviews. It is a recommendation that this improvement takes place. Discussion with residents and sight of health care records confirmed residents were enabled to access primary health care services. A General Practitioner and a Nurse Practitioner visit the care home weekly to provide advice and guidance. A resident spoken to said a chiropodist attends six weekly and that during her fifteen years in residence any health care needs had been effectively met. A relative spoken to expressed concern that bed rails had been removed from his wife’s bed following a risk assessment. The risk assessment when examined was not specific and did not address the potential for inappropriate restraint or entrapment that could cause physical injury. The review of the risk assessment must be undertaken using an appropriate format, involve the resident, her relative and district nursing services. There are plans for all carers handling medicines to complete assessed medicines training. Three carers have already completed this training; two were spoken with during the inspection and were enthusiastic in their support for the proposed improvements in the management of medicines. All carers will be assessed in the application of creams, and the nurse practitioner will provide training in blood glucose monitoring. Completion of all planned training is considered central to improving the management of medicines in the home and must be completed. Good practice was observed in the management of the medication rounds by the trained carers. The medication administration records (MARs) were generally up-to-date but some concerns were identified in the management of ‘when required medicines’ and the home is required to include details about the use of ‘when required’ medicines within individual plans. Additionally, one MAR incorrectly indicated that eye drops had been administered when in fact none had been given. The medication administration records must be complete and accurate. There are plans to improve medicines security by moving to one central medication room. The ‘fridge was not consistently maintaining the correct temperature; the manger was aware of and addressing this issue. Discussion and observation confirmed that residents were treated with dignity and respect. Staff members were observed to be courteous and polite. Improvements had been made to the handling of mail, on behalf of residents, Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 Page 13 as requested previously. Residents were suitably clothed, addressed politely and their independence was being promoted. The policy of the care home was to support service users through terminal illness providing this was practicable and remained in the best interest of the individual. Procedures were in place to guide staff in care of the dying and attempts had been made to arrange relevant training. It was agreed that appropriate training should be sourced to enable further development of staff knowledge and skills in this area. Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 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 Residents had the opportunity to be involved in a wide range of individual and group activities that encouraged stimulation. Residents were enabled to see their chosen visitors in a safe and private environment. Personal support and services provided by the home ensured that residents were enabled to exercise choice and that independence was maintained. Meals of a high quality were produced that were appealing and aided the health and nutrition of residents. EVIDENCE: Residents were observed to be expressing their choice in relation to routines of daily living and meal times. A number of residents were taking breakfast in their room whilst others were having additional breakfast in the dining room as they had chosen to get up early. A member of care staff explained that residents were given breakfast by night staff if they wanted to get up before day staff came on duty. It was said that this system was working well to the satisfaction of all care staff and it was better meeting the needs of residents. Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 Page 15 A record of residents’ interests and preferences in regard to activities was held on the care plan. A dedicated activities organiser planned and presented activities and arranged outings as advertised on posters that were visually attractive. Staff members also engaged residents in practical tasks, where appropriate, as a means of maintaining independence and providing stimulation. In order to evidence inclusion of all residents in the process it was recommended that a log be established in which consultation, participation and satisfaction levels were recorded. The home’s visitors’ procedure indicates that visitors are made welcome and enabled to see their relatives in private should they so wish. Residents and relatives spoken to confirmed that this was the case and that they were pleased with the present improvements. One relative said, “The home has improved so much” whilst another wrote “ “the home is definitely on its way up.” Residents are enabled to handle their own affairs as far as practicable. Advocacy information is clearly available in the Statement of Purpose and Service User Guide. Rooms were personalised and reflected the individuality of the resident. Access to care plans was enabled as confirmed by residents spoken to. Menus indicated that meals were balanced and nutritious aiding health and appetite. Residents when spoken to confirmed that meals were “good.” The dining area was spacious and had a homely ambience. Staff were observed to provide suitable assistance to residents and enable a relaxed pace in the dining room. Refreshments were provided at regular intervals and special diets were catered for. Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 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 The policy and procedures relating to complaints enabled concerns of residents to be heard and addressed. Suitable procedures and training were in place to ensure residents were protected from abuse. EVIDENCE: Complaints information and records were examined and found to meet requirements. Amendments to the text had been made as previously required. The complaints log indicated that two complaints had been received and dealt with satisfactorily by the home during November. Information about how to complain was clearly available for residents. Staff demonstrated an understanding of the complaints procedure in practice. A member of staff said she would “try to resolve” complaints of a minor nature made directly to her, and would refer anything more serious to her line manager for attention ensuring that complaints were listened to at all levels. A robust adult protection policy was in place that included procedures relating to whistle blowing and how to deal with verbal or physical aggression. Adult protection training had been provided for staff. All new staff members were in the process of attending a mandatory training course entitled “welfare of residents”. The course included practical guidance on adult protection matters as a means to ensure all staff would be suitably equipped to identify signs and symptoms of abuse. Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 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 and 26 Significant improvements had been made to the environment that increased the comfort and ambience for residents. The premises were clean and hygienically maintained to protect the health of residents. EVIDENCE: Work had commenced to improve the interior of the home and there had been significant improvements to bedrooms and communal areas. The environment was warm and comfortable at the time of inspection. A refurbishment plan was seen that outlined further work to be addressed. Satisfactory remedial action had been taken in response to recent requirements made by the Fire and Rescue Service. Maintenance records were available for examination. Although it was evident that maintenance tasks had been completed the maintenance log had not been fully completed. It was Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 Page 18 recommended that records are updated effectively to confirm that health and safety matters had been addressed promptly. The premises were clean and hygienically maintained at the time of inspection. Comprehensive infection control procedures were in place. A recent outbreak of diarrhoea and vomiting had been successfully contained through suitable and prompt intervention. The laundry area was clean and tidy with adequate equipment and facilities in place. There was a separate secure sluice facility. Compliance with the Water Supply (Water Fittings Regulations) 1999 was not in evidence and this therefore remains a recommendation to ensure all facilities are totally safe. Kitchen cleaning schedules were incomplete on days when agency staff members were employed to assist. It was recommended that cleaning records be maintained correctly at all times to provide evidence of effective practice. Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 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 and 30 Staffing numbers and the skills mix were adequate to meet the needs of residents. Recruitment and selection procedures had improved thereby ensuring that only people suitable to work in a care environment are appointed. Personnel support systems were inadequate as staff members were working without a signed agreement to the terms and conditions of their employment. Training opportunities that enabled staff to develop knowledge and skills and gain qualifications relevant to their role were provided. EVIDENCE: A suitable number of staff members were on duty at the time of inspection. Staff rotas indicated that staffing was in accordance with regulatory requirements and took into consideration the dependency needs of residents. There had been a reduction in the use of agency staff and a successful recruitment drive had taken place. Staff records showed that an element of hours worked by senior care staff members were being attributed to nursing hours. The administrative recording system should be amended to reflect the hours worked by senior staff to avoid misinformation. Due to recent staff changes there were less than 50 of staff qualified to NVQ Level 2. Further staff had registered for NVQ Level 2. The manager expressed Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 Page 20 her intention to exceed the recommended percentage within a reasonable time frame. Personnel files examined, of the last two staff recruited, demonstrated that correct procedures had been followed. Criminal Bureau Records clearances and references had been received before appointment commenced. An issue of concern was that staff members had not been issued with a contract of employment. One staff member spoken to, that had been in post several months said she had been unwilling to accept a job description or sign a contract that was incorrect as it had been issued in the name of the previous company that no longer existed. To ensure that the proprietors and staff have a common signed agreement about role and purpose and terms and conditions of employment it is required that this matter be addressed as a priority. Training records showed that a number of training initiatives had been introduced. Forthcoming training was clearly displayed for staff and included nominations for attendance. Seven people had undertaken dementia awareness and a further five staff were to attend the next course. A senior member of staff is to become a key trainer in this topic, in liaison with the Alzheimer’s Society, a role that she was positively responding to. New staff were undertaking mandatory training including food hygiene, moving and handling, health and safety, tissue viability and resident welfare as was evidenced through attendance on the day of inspection. Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 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): 31, 33, 36 and 38 Improved management procedures were reflected positively in the day to day management practices of the home. Polices and procedures were not being reviewed within stated timescales and it was unclear whether staff were reading the guidance provided. Supervision systems were in place but supervision timescales were not being adequately met. Health and safety policies and practices were in need of some improvement to fully ensure the health and safety of people living and working at the care home. EVIDENCE: The manager, who had been in post six weeks at the time of inspection, is a qualified nurse and has extensive experience of managing care services for Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 Page 22 older people. The manager demonstrated an understanding of her role and responsibilities. Senior staff members were aware of lines of accountability and displayed a clear commitment to continuous improvement. In order to fulfil the role requirements the manager should complete the application for registered manager, and register for NVQ Level 4 in Management, as a priority. Quality assurance systems were being developed. Evidence was available that relatives had been contacted in order to invite their contribution to care planning and reviews. Polices and procedures were referred to as Clinical procedures and were not totally up to date. Also staff had not signed the provided checklist to confirm that policies had been read and understood. It was recommended that these matters be addressed to ensure all practical guidance is relevant to care services, up to date and read by staff. Supervision procedures had improved. However in practice the system wasn’t being fully implemented and a number of supervision sessions were overdue. Senior staff confirmed their understanding of their role within this procedure and that plans were in place to address the shortfall. It was recommended that care staff receive formal supervision at least six times a year to ensure that adequate guidance and support was made available. Procedures and training opportunities were available to support development of good care practice. All new staff members were receiving induction and mandatory training to equip them to competently fulfil their role. Gas and electrical safety certificates were up to date. Water temperatures at source, and in bedrooms, had been regularly checked and were being maintained close to temperature as required. Because of the frequent occurrence of accidents and incidents involving residents the manager had undertaken an analysis to identify whether there were any common themes emerging. It was requested that the analysis and the conclusions reached be forwarded to the CSCI (Commission for Social Care Inspection) by mid December, for information purposes. As previously noted maintenance and kitchen cleaning records were not fully completed. Also bed rails risk assessments must be reviewed to ensure safe working practices. Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 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 2 X 3 X X 2 X 2 Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 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 OP3 Regulation 14 (1) (d) Timescale for action The pre admission process must 15/12/05 include written confirmation of whether or not a residential place can be offered. Risk assessments and reviews of 31/12/05 risk assessments relating to the installation of bed rails must be undertaken using a suitable format involving the resident, their representatives and district nursing services. 03/01/06 Requirement 2 OP8 13 (6) (7) 3 OP9 4 OP9 18 (1) (c ) The provider must ensure arrangements are agreed for completion of assessed training in: • the safe handling of medicines including creams; • blood glucose monitoring 13 (2) The provider must ensure that the medication administration records are complete, clear, accurate and up-to-date. 23/12/05 Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 Page 25 5 OP9 13 (2) The provider must ensure that information regarding the use of ‘when required’ medicines are included in care plans. The provider must monitor the ‘fridge temperature and provide alternative storage if the appropriate temperature range cannot be maintained. 23/12/05 6 OP9 13 (2) 12/12/05 7 OP29 18(1)(a) Employment practices must be 31/12/05 Sch4(6)(f) improved to ensure that contracts of employment are issued to all staff and a copy is retained on their personnel file. 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 5 6 7 8 9 Refer to Standard OP7 OP9 OP9 OP12 OP26 OP28 OP11OP30 OP31 OP33 Good Practice Recommendations Care plans and care plan reviews, should be signed by the resident or their representative. Consideration should be given to the implementation of the homely remedies policies and procedures. The secure storage of patients’ medical records should be discussed with the GP. Consultation, participation and satisfaction relating to activities and outings should be recorded. Evidence of compliance with the Water Supply (Water Fittings) Regulations 1999 should be available for inspection. 50 of care staff should hold NVQ Level 2 Training relating to care of the dying should be sourced The manager should complete the application for registered manager procedure, and register for NVQ Level 4 in management. Policies and procedures should be kept under review. Staff should sign to confirm that they have read and understood. DS0000065186.V260359.R01.S.doc Version 5.0 Page 26 Withy Grove Care Home 10 11 12 13 OP33 OP36 OP19OP38 OP38OP26 Reference to clinical procedures and nursing hours should be removed from care procedures and care hours records. Care staff should receive formal supervision at least six times a year. Maintenance action plans should be kept up to date at all times. Kitchen cleaning schedules should be kept up to date at all times. Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Chorley Local Office Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW 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 Withy Grove Care Home DS0000065186.V260359.R01.S.doc Version 5.0 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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