Inspection on 12/04/07 for Wrea Bank Residential Home

This inspection was carried out on 12th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Wrea Bank Residential Home 20/06/06

Wrea Bank Residential Home 23/02/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Wrea Bank Residential Home 20 Edge Lane Chorlton Manchester M21 9JF Lead Inspector John Oliver Unannounced Inspection 12th April 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wrea Bank Residential Home DS0000064866.V335888.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. Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wrea Bank Residential Home Address 20 Edge Lane Chorlton Manchester M21 9JF Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0161 861 8444 F/P 0161 861 8444 Lymburn Limited Anne-Marie Thompson Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 18 older people (OP) may be accommodated. The staffing arrangements at the home must be maintained in line with the minimum levels set out in the guidance published by the Residential Forum `Care Staffing in Care Homes for Older People`. 20th June 2006 Date of last inspection Brief Description of the Service: Wrea Bank is a residential home providing accommodation and personal care only for up to 18 older people. Accommodation is provided in 12 single and 3 double bedrooms. Two of the single rooms have en-suite facilities. The home has two lounges, a dining room and a conservatory. Wrea Bank is located South of city centre with access to public transport links into Manchester City Centre, Chorlton and Stretford shopping centres. The home is set in large well maintained gardens which are accessible to residents. A large car park is available to the front of the building. At the time of this visit to the service weekly fees ranged from £368.09 £390.00 per week. Additional charges are made for hairdressing, newspapers and toiletries. Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been written using information held on the Commission for Social Care Inspection (CSCI) records, information provided by people who use the service, staff in the home and by the manager. A site visit to Wrea Bank took place on 12 & 13 April 2007 over a total period of nine hours and the home was not told about the visit beforehand. During the visit the inspector had a look around the home and looked at paperwork that must be kept by the home to show it is being run properly. Another way that was used to find out more about the home was by talking with some of the residents, staff and visitors who were in the home on the days of the visit. The registered manager had left and a senior member of staff has been appointed to the role of temporary manager. Further discussion with this manager indicated that he would soon be making an application to the CSCI for registration. What the service does well: Wrea Bank provides a warm, friendly and welcoming atmosphere where the individuality of people living in the home is promoted. Staff are encouraged and enabled to spend time sitting and chatting with people. The manager and staff of the home have continued to work hard providing and developing a positive, high standard service to the people living in the home and comments from people included: * * * * “Staff are really good – we want for nothing” “Living here is wonderful – we are treated as individual people” “You do get plenty of choice here” “The new cook is good – the food is always good here”. People living in the home have their own ‘committee’ with a chairperson and secretary which meet on a regular basis to discuss issues relating to various subjects with minutes being kept. This ensures each person living in the home has an opportunity to express their own opinions in a suitable forum. Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 6 People living in the home were very clear about who they would go to should they have a concern or a complaint. Activities in the home are particularly well organised with a dedicated ‘activities organiser’ on the staff team. Relatives spoken to during the inspection visit were very complimentary about the service provided by the home and comments included: * * “Care is very good – no problems” “Everything’s fine – wonderful – very happy with everything”. What has improved since the last inspection? What they could do better: Although the overall appearance of the home was well kept and provided comfortable space for people to use some areas were beginning to show signs of ‘wear and tear’ especially in some of the bedrooms. The rolling programme of maintenance and refurbishment had not been kept up to date and was last reviewed in October 06. Although people spoken with said that the food supplied in the home was good and, evidence seen on the days of the visit confirmed this, no records were kept of the food prepared and served on a daily basis. Lack of such information made it difficult for the manager to demonstrate that the home served food that was varied and nutritious. Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 7 Vetting procedures for new staff had not been fully adhered to which resulted in some important information not being available prior to a person starting work in the home. Lack of such important information could place people at risk from exposure to unsuitable staff. Although policies and procedures were available and were accessible to all staff, these had not been reviewed or updated for a number of years. As this type of information is made available to offer staff advice and support when carrying out their work it is therefore very important that this information is correct and up to date. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wrea Bank Residential Home DS0000064866.V335888.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 Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the service is made available to assist people to make an informed choice about moving into the home. People’s needs are assessed before moving into the home. EVIDENCE: The manager stated that he had recently updated both the Service User Guide and Statement of Purpose to reflect the changes in the management structure of the home. Copies of both documents were provided and copies were on display in the hallway of the home although people living in the home had not been given their own copy. There was however, evidence that the new management structure had been fully discussed with the people living in the home during one of the committee meetings. Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 10 There had been two new admissions to the home since the last visit took place and the files of these admissions were examined along with two other randomly selected files. Three of the four files contained an assessment undertaken by a community based professional and all four files contained a pre-admission assessment carried out by the manager of the home. Information appeared to be sufficient for the manager to make a decision about whether or not they could meet the person’s needs. It would be seen as good practice if the manager wrote to all interested parties following assessment that the home could/could not meet the person’s needs. Wrea Bank does not offer Intermediate Care. Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning processes within the home included all aspects of health, personal and social care although information could be further expanded. The administration and handling of medication was well managed. EVIDENCE: Four people’s files were looked at. All had a copy of a written care plan but the care plan format used is based on a nursing model and, therefore, some the section headings may be inappropriate for use in a residential setting and may cause confusion to staff completing them. Evidence of this was seen under the heading ‘Controlling Temperature’. One plan stated that the person “knew when they were hot and cold”, others were left blank – indicating staff appeared unsure how to complete the information. Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 12 Examination of the individual care plans demonstrated that the plans were regularly reviewed with the involvement of the person and/or their advocate where possible. One person living in the home said, “I get asked about my care plan regularly – we do this in my room”. Some care plans were more detailed in the information they contained than others especially regarding how assistance should be offered to the individual person. One example being, “needs assistance with dressing” which is not specific enough to enable a carer to assist the person in the most appropriate way. It is important that people are assisted in such a way that enables their privacy, dignity, choice and independence to be maintained at all times. Risk assessments were available on each file but lacked sufficient detail for them to be of specific use. One assessment stated “at risk of slips, trips and falls” but did not specify what the actual risk was and how the risk(s) was to be managed. It was also difficult to link the risk assessments to the actual individual care plan as the risk stated on some care plans was different to the risk identified in the actual risk assessment. Examination of the records completed by staff each day and night to detail the care and support given to an individual person contained enough information to demonstrate this. At the time of this visit the manager confirmed that no person had pressure sores. Those at risk did have pressure relieving equipment in place and records seen of visiting professionals demonstrated that matters of maintaining health were seen as important by the manager and staff of the home. Wrea Bank uses a pre-dispensed monitored dosage system for administering medication. Medication was appropriately and securely stored and medication administration records presented as predominantly appropriately maintained and correct. Medication to be administered ‘as and when’ required was difficult to check as no running total of balances were maintained. Also, the directions for the administration of some medication (eye drops) stated ‘as directed’ which, could put the individual person at risk from the medication being administered at the wrong times. Observation of care practice indicated that the support and interventions of staff promoted people’s privacy and dignity and comments from people living in the home included, “Living here is wonderful – we are treated as individual people” and, “Staff are really good – we want for nothing”. Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good range of recreational opportunities is available and people are supported and enabled to fulfil their individual wishes and choices. Food was of a good standard. EVIDENCE: One member of the care staff team has the responsibility for offering a range of recreational activities to people living in the home. These included arts and crafts and evidence of these activities were displayed throughout the home. A focal point in the hallway of the home is a large notice board displaying information relating to the social events taking place in the home. Also displayed on this notice board was information relating to different cultures, religions and beliefs and appropriate pictures and photographs were in place that supported this information. The activity organiser was on duty at the time of the visit and was able to demonstrate the type of activities arranged. Information about what each person likes to do and to be involved in is kept in a large file that is updated on Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 14 a monthly basis. The people in the home have their own committee with a chairperson and secretary which meet on a regular basis to discuss issues relating to various subjects with minutes being kept. People living in the home confirmed that activities took place on a regular basis and trips had been arranged to places such as Granada Studios to watch television programmes being recorded. Visitors spoken to during the visit confirmed that they continued to be encouraged to visit the home to see their relative and are always made to feel welcome. People spoken to confirmed that they were able to choose when they got up or when to bed. The routines of the home presented as being suitably flexible for people to exercise choice and autonomy wherever possible. One person had a telephone and refrigerator in her room and another held a key to her door. Since the last inspection visit in June 2006 a new cook had been employed to work in the home. The meal provided on the day of the visit was pleasantly presented and was served to people in the dining room. People were offered a choice of meal or could have some of ‘everything’ if they wished. Tables were appropriately set and, throughout the meal, staff were observed to be offering people assistance where this was needed and this was carried out in an unhurried manner and people were not rushed to finish their meals. Comments about the food served included, “The new cook is good – the food is always good here” and, “You get plenty of choice here”. The cook did not use set menus nor did she keep a record of the food prepared on a daily basis. This makes it difficult to assess if the food being prepared and served provided a varied and nutritious diet. Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home feel safe and that their complaints would be listened to and taken seriously. EVIDENCE: Wrea Bank has an appropriate complaints procedure. This was included in the Service User Guide but did need the recent change of address of the local office of the Commission for Social Care Inspection updating. People spoken to felt safe and secure and would be comfortable speaking with staff and the manager if they were not happy about anything in the home. Comments included, “I would go to Daren (manager) he would sort it out for me”, “I am quite confident that there would be no reason to complain but if there was I know my mum would go to Daren”. Discussion with the manager confirmed that no complaints had been received since the last inspection visit. The complaints register was made available and staff spoken to were also very clear about the complaints procedure that is in place. Staff had received training in the protection of vulnerable adults and the member of staff spoken with was able to give a clear demonstration of their understanding of the action they would take should an allegation be made. Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 16 However, failure to effectively obtain all relevant pre-employment information for new staff could compromise the safety of people (see section on staffing). Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Failure to maintain a programme of renewal and refurbishment for the home could place people at risk. EVIDENCE: On day one of the site visit a partial tour of the building was undertaken which included a number of people’s bedrooms. A number of minor repairs were identified. This included broken drawer fronts, loose floor plates (covering carpet edges) and loose toilet seats. What was more concerning was that a number of bedrooms had unguarded radiators that had not been risk assessed, posing a potential risk to the health and safety of the people whose rooms they are. Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 18 However, it is acknowledged that on returning to the home the next day, it was found that the manager had taken appropriate action and had audited all bedrooms and completed risk assessments for those bedrooms with unguarded radiators. There was evidence of work that had been undertaken to redecorate and recarpet some of the bedrooms and there was evidence that some people had personalised their own rooms to reflect their character. The carpet in the bedroom identified to the manager that is in a poor state, was uneven and had a small hole in it must be replaced, as there is a potential risk to the health and safety of the person whose room it is. The furniture and decoration in this room was also in need of updating sooner rather than later. The bathroom near room 15 was being used for storage and the bath contained two mattresses. Although the manager said that this bathroom was not used by people living in the home it was still a potential risk to their health and safety and must be cleared of all stored items. The top floor of the premises was previously used as the sleeping in facility for the manager when on call. However, this has not been used for this purpose for quite some time and is now used as a storage area. It is accessed via a flight of stairs and is accessible to anyone capable of using those stairs. The health and safety of any person living in the home could be compromised should they enter this part of the building and appropriate action must be taken to minimise this risk. There was clear evidence that work to the fabric and maintenance of the building and grounds was being undertaken but this was being carried out in more of an ad hoc manner than following any planned maintenance and renewal programme. There was still significant room for improvement in the décor of some of the rooms seen and, similarly some commodes and other furnishings would benefit from replacement. Lounge and dining areas were well set out and provided appropriate, comfortable areas where people are able to talk to each other easily. The home was generally clean and tidy and people spoken to said that the staff in the home “maintained a high level of cleanliness”. Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff is adequate to meet the needs of residents. People in the home are potentially at risk by the home’s recruitment procedures not being applied properly. EVIDENCE: The home’s rotas provided evidence that sufficient staff were being deployed to meet the assessed needs of people living in the home. People spoken to confirmed the availability and helpfulness of staff during the night as well as during the day time. People were positive in their comments about the care they received from staff, as were the relatives spoken to. Comments included, “Staff do their best at all times”, and, “I know my mum is well cared for”. Staff who were spoken to, indicated that the staffing levels in the home were adequate for them to perform their duties to a good standard. The manager reported that of the 12 carers working at Wrea Bank 8 held the National Vocational Qualification Level II or above which is above the guidance in the National Minimum Standard of 50 of the staff group being qualified to NVQ II. Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 20 Evidence was seen on the files of those newly employed staff that a basic induction had been carried out and that further basic mandatory training had been arranged. At the time of this visit the manager was in the process of reviewing and updating all staffs training records. Each member of the staff team had an individual training log on file. The manager confirmed that various mandatory training had taken place. Evidence was available to show that staff had been booked on further training e.g. medication and Protection of Vulnerable Adults (POVA). It was confirmed by staff spoken to that training had been undertaken and included, medication training, moving and handling, first aid, protection of vulnerable adults and, NVQ Level II. The files and documentation held on staff most recently employed by the manager was looked at. Files were comprehensive in their contents but did not include a Criminal Record Bureau (CRB) disclosure or POVA First. The manager said that he had completed these but they had been returned because he had not completed them correctly. However, on the second day of the visit the manager had re-applied for CRB’s and POVA First checks and appropriate action had been taken to provide supervision and monitoring to these staff whilst these checks were being carried out. Employing staff in the home before satisfactory pre-employment checks are in place can place people at risk of unsuitable staff being employed. Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, management and administration arrangements were meeting the needs of the people using the service. EVIDENCE: Since the last site visit in June 2006 the previous registered manager had left the home. The registered person informed the Commission for Social Care Inspection (CSCI) about this at that time and reported that a new manager had been appointed from the existing staff team. At the time of this site visit, an application to register Mr Wills as the manager of Wrea Bank had not been received by the CSCI. Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 22 Evidence seen during this site visit demonstrated that the manager was providing leadership and guidance to the staff in the home on a day to day basis. Comments from people living in the home, their relatives and staff demonstrated that they were clear who the manager was and felt that the manager was doing a “good job”. There was no ‘formal’ quality assurance system in place although the views and opinions from people living in the home were sought during the regular committee meetings that are held. The home does not manage personal finances for any person living in the home. These are handled either by relatives or other advocates. If a person is admitted with cash or cash is brought in by relatives for items such as hairdressing it is recorded, signed for and receipts obtained. Staff spoken with said that they felt “supported” and were given “guidance” by the new manager. They also confirmed that regular one to one supervision took place and that records were kept of these sessions. A sample of records relating to the maintenance of equipment at the home was looked at. Fire detection and alarm equipment had been appropriately maintained and regular staff fire drill training had been carried out. No fire risk assessment was in place for the premises and the manager must contact the local Fire Service to take further advice on this matter. A policies and procedures file was in place but this had not been reviewed nor updated for a number of years. Wrea Bank Residential Home DS0000064866.V335888.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 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 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 3 3 X 2 Wrea Bank Residential Home DS0000064866.V335888.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 13 (4)(c) Requirement The registered person must ensure that risk assessments, relating to the individual person, are in sufficient detail to demonstrate what has been looked at and considered and what needs to be done to reduce the risk of an accident to the person. The carpet in the bedroom identified to the manager that is in a poor state and poses a risk to the health & safety of the person whose room it is must be replaced. The bathroom near room 15 must be cleared of all stored items. Appropriate action must be taken to minimise the risk to people living in the home from entering that part of the premises previously used as a ‘sleeping in’ facility. Timescale for action 25/05/07 2. OP19 13 (4)(c) 25/05/07 13 (4)(c) 13 (4)(c) Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 25 3. OP29 19 4. OP31 8&9 5. OP38 23 (4) The registered person must 25/05/07 ensure that CRB/POVA First disclosure, satisfactory written references and all other preemployment information is in place before any member of staff commences employment to minimise the risk of exposing people living in the home to unsuitable workers. The registered person must 25/05/07 ensure that an application for a manager to be registered with the Commission for Social Care Inspection must be made. The registered person must 25/05/07 contact the local Fire Service and following advice develop a fire risk assessment for the premises. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 OP3 Good Practice Recommendations It is strongly recommended that all people living in the home are provided with a copy of the updated Service User Guide and Statement of Purpose. It is recommended that following the pre-admission assessments, the manager writes to all interested parties to inform them that the home can/cannot meet the individual persons needs. It is strongly recommended that information contained within a care plan is completed with ‘more specific’ detail as to how individual assistance is to be offered. It is recommended that consideration be given to using a more appropriate style of care planning format. It is recommended that risk assessments ‘link’ to individual care plans for consistency of such information. DS0000064866.V335888.R01.S.doc Version 5.2 Page 26 3. OP7 4. 5. OP7 OP7 Wrea Bank Residential Home 6. 7. OP9 OP9 8. 9. OP15 OP16 10. 11. OP19 OP19 12. OP38 It is strongly recommended that two staff complete all handwritten information/changes on medication administration records. It is strongly recommended that all medication should have specific administration instructions (rather than ‘as directed’) and that medication to be given ‘as and when required’ should have a ‘running total’ in order that balances of medication can be checked. It is strongly recommended that records are kept of the food that is prepared on a daily basis. It is strongly recommended that the contact details relating to the Commission for Social Care Inspection be updated to reflect the recent change of address and telephone numbers. It is strongly recommended that the programme of redecoration and renewal of furnishings and fittings be reviewed and updated. The registered person should ensure that there is an effective system in place to identify and address minor remedial items (repairs and replacement) in connection with the building. It is strongly recommended that all policies and procedures be reviewed and updated where necessary. Wrea Bank Residential Home DS0000064866.V335888.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wrea Bank Residential Home DS0000064866.V335888.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. 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