Inspection on 02/03/06 for Wrottesley House

This inspection was carried out on 2nd March 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wrottesley House 04/09/06

Wrottesley House 13/09/05

Wrottesley House 20/01/05

Wrottesley House 24/08/04

Wrottesley House 05/02/04

Similar services:

Maple Lodge

Heathlands

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Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Wrottesley House 46 Wrottesley Road Tettenhall Wolverhampton West Midlands WV6 8SF Lead Inspector Bhag Jassal Unannounced Inspection 02/03/06 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 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. Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Wrottesley House Address 46 Wrottesley Road Tettenhall Wolverhampton West Midlands WV6 8SF 01902 744609 01902 744609/565522 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) Wrottesley House Ltd Anne Younger Care Home 18 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (18) of places Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All DE category service users must be accommodated on the ground floor. The agreed staffing levels are: 8am - 9pm Senior Carer 2 care staff Night staffing 2 waking care staff Care Manager hours are supernumerary Separate catering/domestic/laundry staff/activity organiser must be provided in addition to care hours. These are minimum staffing levels and must be increased in the event of any increase in dependency of service users accommodated. CSCI will continue to monitor the staffing levels and may require levels to be increased should CSCI feel that care needs are not being met. Date of last inspection 13th September 2005 Brief Description of the Service: The home is situated in a residential area of Tettenhall about half of a mile from Tettenhall Green, and approximately three miles from Wolverhampton City Centre. The home is in close proximity to a main arterial road. The home was built over 26 years ago as a large, detached private dwelling and has since been adapted and extended to accommodate 18 service users. Six of the bedrooms have an en-suite facility. At the front of the premises there is a parking area together with flowerbeds and shrubs. The rear garden is well laid out with lawns and borders. There is one double bedroom and the remaining 16 bedrooms are single. The home has adequate bathrooms/showers and WCs. There are two lounges, a dining room, laundry room, an office and a staff room. Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 9.00 am and lasted 5 hours and 40 minutes. The inspection included discussions with the Registered Manager, staff, service users and their relatives. The daily routines were observed and service users and staff records, policies and procedures were examined. The inspection of premises both inside and outside and facilities were also undertaken. What the service does well: What has improved since the last inspection? Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 6 The home has made good progress in implementing the requirements from the last inspection. The home has provided training in safe handling of medication to several carers. However, it is the home’s policy that only the senior members of staff would be responsible for safe handling of, and administration of medication to service users. The NVQ Level 2/3 and safe working practice topics training has been implemented. All staff have been CRB and POVA checked. All new members of staff are receiving the Skills for Care Council’s Induction and Foundation training. All members of staff (with the exception of two new members of staff) have received training in protection of adults from all forms of abuse. Six carers have completed their training in Dementia care. The home has implemented a programme of social and leisure activities and appropriate records are now being maintained. All the service users’ care plans are being reviewed on a monthly basis. The home has continued to redecorate bedrooms and communal areas. All the requirements and recommendations contained in the recent inspection reports of the Fire Safety Officer and the Environmental Health Officer have been appropriately implemented. New carpets have been provided in the corridor leading to the Manager’s office, the back stairs and in the corridor leading to the quite lounge. A radiator in the bathroom/WC used as en-suite facility next to bedroom on the first floor has been covered appropriately for the safety of the service users. Fire risk assessment in the home have been updated. The vacant posts of a senior carer and a carer have been filled. All members of staff are receiving their formal supervision meetings at the required intervals. The Registered Manager has completed her NVQ Level 4 in care and management qualification. What they could do better: The home must continue to update the service users’ needs assessments, risk assessments and care plans. The home must continue to improve further the quality of daily care recordings. Those members of staff who as yet have not received training in safe working practice topics, NVQ Level 2 and safe handling of medication must do so as a matter of priority. This training would enable staff to improve further their care practices and professionalism. There are three minor issues relating to the environment, which must be addressed as a matter of priority. The Registered Manager must take swift action to progress further the home’s Quality Assurance annual development plan and outcomes for the service users. Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 7 Overall, the home has made good progress in complying with the requirements arising from the previous inspection report. It is also acknowledged that steady improvements are being made to care practices and the home’s environment by the staff, Registered Manager and the Registered Providers. 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. Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 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 Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 The home provides clear and accurate information to prospective service users on the services provided, enabling them to make a properly informed choice about the home. All the service users are given a written contract/statement of the terms and conditions of residence on admission to the home. The home has a good admission procedure providing an effective needs assessment and its ability to meet the assessed needs of both privately funded service users and those placed by the Local Authorities – which needs updating. EVIDENCE: The home provides clear and accurate information to prospective service users on the services provided, in the form of a Service Users’ Guide and Statement of Purpose for the home enabling them to make a properly informed choice about the home. Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 10 There was evidence on service users’ individual files to show that all the service users are provided with a contract/statement of the terms and conditions of residence at the time of admission. A sample of three service users’ care plans and files were thoroughly examined at the inspection. All contained evidence that the service users receive the benefit of a comprehensive assessment prior to admission. The Registered Manager stated that she carries out assessments on both self-funding service users and those placed by the Local Authorities. The assessment details are documented on the service users’ care plans. The care plans are drawn up by the senior staff with the assistance from the service users, their relatives and where appropriate other professionals. However, it was noted that the needs assessments and risk assessments were in need of updating. The Registered Manager stated that in conjunction with the senior carers they will review and update all the service users’ needs assessments and risk assessments by the end of March 2006. The home has a good admissions procedure, which is made available to all prospective service users, their relatives and/or representatives. The service users and/or their relatives can visit the care home prior to admission. If they indicate that the care home is able to meet the needs of the prospective service users, then the home confirms this in writing. Once this is agreed between the parties concerned, then the placements take place on a 28 days trial period. Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 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 and 9 The staff within the home are aware of and sensitive to the needs of each and all service users and meeting their needs in a professional manner. There are clear and consistent care plans in place, which provides the information the staff requires to meet the service users’ health and care needs. EVIDENCE: It was evidenced that all service users undergo a comprehensive assessment of their needs prior to admission to the care home. A care plan is produced, which is based on the assessment of needs. The home operates a key worker system, which helps to ensure that the recommendations arising from the care plans and monthly reviews are implemented. Three service users’ care plans were examined in detail and it was noted that the short-term and long-term goals and appropriate interventions required to put them into action to meet the individual service users’ needs are identified. It was noted that the care plans are being reviewed on a monthly basis. The daily care (day and night) recording formats were also examined and it was noted that the quality and detail of recording has steadily improved but need Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 12 further improvement. The Registered Manager stated that the staff will be closely supervised and supported to make further improvements in daily care recordings. It was evidenced that the home ensures that the detailed nutritional screening is undertaken, including weight gain and loss records are maintained and appropriate action is taken if required. The home also maintains records of all health checks. The case tracking demonstrated an effective review process together with the home’s ability to meet the changing needs as they occur. The service users’ health is closely monitored and appropriate medical care services are sought as and when required. The Inspectors spoke to ten service users, who were able to have meaningful conversations. Generally the service users appeared to be content, comfortable and happy. It was evidenced from the staff records and from discussion with the Registered Manager that seven members of staff have completed their training in safe handling of medication. There are four senior carers out of these seven members of staff, who are responsible for the safe handling and safe administration of medication to service users. It is the home’s policy that only the senior carers would be responsible for the safe handling and administration of medication. There are five carers who currently undertaking training in safe handling of medication and the remaining four carers will also undertake this mode of training shortly. Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 Wrottesley house care home provides a good standard of care and promotes individual lifestyles for the service users in residence. The service users are positively helped to exercise choice and control over their lives as far as practicable and safe to do so. Meals at Wrottesley House are of good homely type, offering both choice, variety and catering for special dietary needs and requirements. EVIDENCE: It was evidenced that the home now provides an activities programme in accordance with the service users’ choices, preferences and capacities in relation to social, leisure and cultural interests. The records of activities enjoyed by the service users are now being appropriately maintained. The Registered Manager stated that the staff will be asked to ensure that the activities enjoyed by the service users are appropriately incorporated into their individual care plans. The Registered Manager stated that the home positively helps the service users to exercise choice and control over their lives as far as possible and practicable. A close liaison is maintained with the relatives and representatives, where the service users are not able to make certain Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 14 decisions. The service users and their relatives are informed of the availability of the Advocacy Service based at the local Age Concern. The information about the Advocacy Service is included in the Service Users’ Guide. It was evidenced that the home provided a varied, wholesome and nutritious diet. The meals provided during lunchtime on the day of inspection were well received by the service users. It was observed that those service users who needed assistance in feeding, were assisted by staff. The Registered Manager stated that the menu is changed on a regular basis and in consultation with the service users. Several service users told the Inspector that the food was nice, tasty and/or well presented. The kitchen is well equipped and kept clean and tidy. The catering staff are well trained in food safety and hygiene matters. There was adequate stock of food in the home. Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Concerns and complaints are dealt with promptly and professionally. The service users’ rights are promoted and protected. The service users are protected from abuse by the home’s policies and procedures. The arrangements for the protection of service users from abuse are satisfactory. EVIDENCE: The home has a good complaints procedure in place, which is referred to in the home’s Service Users’ Guide and in the Statement of Purpose for the home. There is a system of recording concerns and complaints. It was noted that there had not been any complaints in the home since the last inspection and none had been directed to the Commission for Social Care Inspection (CSCI). The service users spoken to by the Inspector stated that their views and comments are always listened to by the Manage and senior carers. The Registered Manager stated that as far as possible and practicable, the service users’ legal rights are promoted and protected appropriately. Where the service users are not able to make certain decisions, then their relatives and/or representatives are requested to assist, and where appropriate, the local Advocacy Service is also requested to help. The service users are positively assisted to take part in elections and they use their voting rights. The home has a good policy and procedure in place in regard to protection of service users from all forms of abuse. The Registered Manager stated that all staff with the exception of two new staff have received formal training in adult Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 16 protection from all forms of abuse. The adult protection issues are also discussed during induction training and supervision meetings. Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 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, 21, 24, 25 and 26 The general standard of the environment is very good providing service users with a homely and safe place to live. The high standard of cleanliness reflects the ongoing cleaning schedule, which maintains this standard throughout the home. EVIDENCE: The home offers a comfortable and well–maintained environment to all service users. The home has adequate communal space - two separate lounges and a dining room. The home is safe and is suitable for its stated purpose. The home has an ongoing rolling programme of redecoration to maintain good standard. The garden, patio and grounds are well maintained for the use of service users. The home has implemented all the requirements and recommendations contained in the recent inspection reports of the Fire Safety Officer and the Environmental Health Officer. Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 18 The home has provided suitable aids and adaptations in the home to meet the general and specific needs of all the service users. There are adequate numbers of bathrooms/showers and WCs in the home. However, The Registered Providers must ensure that suitable extractor fans are provided in the WCs, which presently are without this facility, in the interest of hygiene. There is good standard of furniture and fittings provided in the service users’ bedrooms. It was noted that many of the bedrooms have been “personalised” by the service users. The level of lighting throughout the home was adequate and the central heating system was working well. It was noted that several bedroom doors self-closures were not closing properly to their rebates. The Registered Providers must ensure that all the door self-closure devices are checked on a regular basis and to ensure that they properly close to their rebates. Hot water outlets in the service users’ bedrooms and in the communal areas are fitted with thermostatically controlled mixer valves. Hot water temperature is tested on a weekly basis and appropriate records are maintained. However, it was noted that there was no cold water supply or adequate hot water supply in the sink in the staff WC. It was also noted that the hot water temperature in several bedrooms was far below (i.e. measured between 30 Degrees C to 35 Degrees C) the required level of close to 43 Degrees C. The Registered Providers must ensure that the temperature of hot water supply in all hot water outlets is maintained close to 43 Degrees C at all times and must take appropriate action to ensure there is cold water supply in the sink in the staff WC. During the day of inspection, the home was found to be clean, tidy and free from any unpleasant odour. The home has good policies and procedures in place regarding infection control. It was noted from the staff training records that 11 members of staff have completed their training in infection control. In addition, all members of staff have received induction training and they are made aware of the dander of cross-infection. Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 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 The home is now adequately staffed, which ensures the quality of care provided, and the ability of the home to meet the needs of the current 16 service users with varying degrees of dependency levels and differing needs. The home continues to support staff to complete training. The home has good staff recruitment policies and procedures. EVIDENCE: The information provided by the Registered Manager and the available staff rotas showed that the home at present is adequately staffed to care for 16 service users with varying degrees of dependency levels and differing needs. The Registered Providers must take appropriate action to ensure that the vacant post of a part-time cleaner (15 hours per week) is filled as a matter of urgency and priority. It was evidenced from the staff training records that one senior carer has completed her NVQ Level 3 and another is currently undertaking her NVQ Level 3 training. Five members of care staff have completed their NVQ Level 2 training and five carers are currently undertaking this training and the remaining five will be commencing this mode of training shortly. The Registered Providers must ensure that the home has a minimum 50 ratio of trained member of care staff with NVQ Level 2 or equivalent. Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 20 Discussion with the Registered Manager and examination of the most recently recruited staff files demonstrated that the home’s recruitment procedures have been followed. The CRB and POVA checks are being undertaken and two written references are being obtained before a new member of staff actually appointed and commences duty at the home. It was evidenced from the staff training records that the majority of the staff have either completed or they have been enrolled to complete or update their safe working practice topics training. There are several remaining members of staff who have been assessed to undergo this mode of training shortly. It was also evidenced from the newly appointed members of staff files that the home is implementing the Skills for Care Council’s (formerly TOPSS) Induction and Foundation training programme. The Registered Providers must take appropriate action to ensure that those members of staff who a yet have not received their training in safe working practice topics training must do so as a matter of priority. It was evidenced from the training records that several members of staff have completed their Dementia care training and other 10 carers have been booked to complete this mode of training shortly. The Registered Providers should consider providing specialist training for staff in Disability Awareness, care practices and recording and management of challenging behaviours. Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 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, 35, 36 and 38 The home is managed by an experienced and qualified Registered Manager. The staff are clear of their roles and responsibilities. Good systems of communication are in place to seek views of the service users and their families/friends. The service users’ monies are appropriately handled by the Registered Manager. The staff are regularly supervised to enable them to carryout their work professionally. Health, safety and welfare of service users and staff are promoted by safe working systems put in place by the Registered Providers and the Registered Manager. EVIDENCE: The Registered Manager has completed her RMA and NVQ Level 4 in care and management qualifications. It was noted that Mrs Anne Younger has introduced a number of changes in order to improve further the care practices and recording formats to enhance the high quality of care for the service users. Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 22 It was evidenced that the home has a Quality Assurance monitoring system in place. The home has received feedback through questionnaires from the service users and their relatives. The responses are to be analysed and a report to be prepared with an action plan as appropriate and to be made available to all the stakeholders and for inspection by the CSCI. The Registered Manager must ensure that all the other elements of the National Minimum Standard OP33 are also fully implemented as a matter of priority. The Registered Providers must provide copies of their monthly visit reports on the conduct of the care home to the CSCI in accordance with Regulation 26 of the Care Homes Regulations 2001. The Registered Manager assists a number of service users with their monies. There is a safe in the home for storage of money and valuables. A sample of three service users’ money was checked and found to be satisfactory. It was evidenced that all the members of staff are supervised at the required intervals. Records of supervision meetings were examined during the inspection. The Registered Manager also holds regular meetings with staff. Accidents and fire prevention records were examined and found to be appropriately maintained. Matters pertaining to fire safety and environmental health were found to be satisfactory and all the issues identified in the recent inspection reports of the Fire Safety Officer and the Environmental Health Officer have been appropriately implemented. The Registered Providers must ensure that all those members of staff who as yet have not received training in safe working practice topics (i.e. moving and handling, first-aid, food hygiene, fire safety, health and safety and infection control) must do so as a matter of priority. (See NMS OP30 above). Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X 2 X X 3 2 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The Registered Manager must ensure that the service users’ care plans are kept up to date and that appropriate action is taken to improve the quality of daily care recordings. The Registered Manager must ensure that al the service users’ needs and risk assessments are updated as a matter of priority. The Registered Providers must ensure that all bedroom doors, including inter-connecting doors self- closure devices must be checked on a regular basis to ensure that they actually close properly to doors rebates. The Registered Providers must ensure that suitable extractor fans are provided in WCs, which are presently without this facility in the interest of hygiene and unpleasant odour in the home. The Registered Providers must ensure that the hot water supply DS0000037696.V275970.R01.S.doc Timescale for action 31/03/06 2. OP3 13 & 14 31/03/06 3. OP19 23 & 37 31/03/06 4. OP21 23 31/03/06 5. OP25 13 & 23 31/03/06 Wrottesley House Version 5.1 Page 25 at the required temperature level (i.e. close to 43 Degrees C) is maintained in all the hot water outlets throughout the home at all times; and that cold water in the staff WC sink is restored as a matter of priority. 6. OP27 18 The Registered Providers must ensure that the vacant parttime post of a cleaner (15 hours per week) is filled as a matter of priority. The Registered Providers must ensure that there is a minimum ratio of 50 trained members of staff NVQ Level 2 or equivalent employed in the home. The Registered Providers must ensure that all those members of staff, who as yet have NOT received training in the safe working practice topics must do so as a matter of priority. The Registered Providers must ensure that the home’s quality assurance annual development plan for the year 2005 is fully implemented. A report of the analysis of the feedback on the quality of services and facilities provided by Wrottesley House must also be made available in the care home and for inspection by the CSCI. The Registered Providers must ensure that copies of the monthly Regulation 26 visits to the care home are sent to the CSCI as a matter of priority. 31/03/06 7 OP28 18 30/04/06 8 OP30 12 & 18 30/04/06 9 OP33 24 15/04/06 10 OP33 26 31/03/06 Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 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 Refer to Standard OP30 Good Practice Recommendations The Registered Providers should consider providing specialist training for staff in management of challenging behaviours, disability awareness, care practices and care recording as a matter of good practice and staff development. Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE 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 Wrottesley House DS0000037696.V275970.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!