Care Home: Cullum Welch Court

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What the care home does well A statement of purpose and service user guide was provided for residents and prospective residents, which included information about the service. Systems were in place to meet the healthcare needs of the residents and care plans were prepared and kept under review. Residents were pleased with the quality of meals provided. The staff team worked together to meet the needs of the residents and ensure residents were treated with dignity and respect. Adequate and appropriate activities were provided. Satisfactory systems were in place to manage complaints, to ensure residents were protected from harm and to manage resident`s personal allowance. The environment was excellent, well maintained and provided a homely and relaxed atmosphere for the people who live in the home. Staffing levels were good and ensured staff had time to spend with residents and provide care in an unhurried manner. Staff were provided with training and supervision to ensure they maintained the skills needed to fulfil their roles. Recruitment procedures were good and staff were recruited in line with regulation. The home was well managed and a satisfactory system was in place to monitor the quality of the service. Attention was given to providing a safe environment for residents and others. What has improved since the last inspection? A risk assessment was completed prior to fitting bedrails. An issue in relation to recording the dose of a medicine administered when a variable dose was prescribed was resolved. The adult protection procedures had been reviewed and amended to show that all suspicions or allegations of abuse are referred to the local authority for investigation. Recruitment procedures had improved. A quality assurance system was introduced to monitor and review the quality of the service. Wound assessment records had improved. Fire drills were held at times to include day and night staff. What the care home could do better: Hand written entries made on administration charts by staff must be countersigned and must reflect the details on the pharmacist label. Accurate records must be kept for all medicines bought into the home. Management must ensure that prescribed medicines are administered to residents according to the prescription. Systems must be in place to monitor compliance with medicines for residents who choose to self-medicate. Management must ensure that risk assessments are completed prior to imposing restrictions to resident`s choice. CARE HOMES FOR OLDER PEOPLE Cullum Welch Court Morden College 19 St Germans Place Blackheath London SE3 0PW Lead Inspector Ms Pauline Lambe Unannounced Inspection 6th November 2008 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 Cullum Welch Court DS0000058195.V373112.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. Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cullum Welch Court Address Morden College 19 St Germans Place Blackheath London SE3 0PW 020 8463 8300 020 8269 1197 ellen@mordencollege.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Cullum Welch Court Sharon Herd Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60) of places Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing (CRH - N) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 60 31st July 2006 Date of last inspection Brief Description of the Service: Cullum Welch Court Care Home is a purpose built care home built by the Trustees of Morden College. The home was registered to provide nursing care for 32 older people and personal care to 28 older people. The home forms part of the overall services provided by Morden College for its residents both on and off site. The home was built to a high standard and to comply with the requirements of the National Minimum Standards. Accommodation is provided on two floors with staff facilities on the third floor. All bedrooms are for single occupancy and have en-suite shower, hand basin and toilet facilities. Adequate communal, bathing and toilet facilities are provided and the home was decorated, fitted and furnished to a high standard. A pleasant and wellfitted hairdressing room was provided. The home is situated in the College grounds and is close to Blackheath Village with its shops and transport facilities. Residents have access to the College social club and other areas including the well-maintained and pleasant gardens. The current weekly fees range from £337 - £888 per week. Residents pay privately for personal items such as hairdressing and toiletries Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. An unannounced key inspection was completed on 6th November 2008. The registered manager was in charge of the home and together with residents and staff assisted with the inspection. The last key inspection of the service was on 31st July 2006 and an annual service review was completed on 1st February 2007. On the day of the inspection 36 residents were in the home and one person was in hospital. No changes to the registration of this service were made since the last inspection. The inspection process included a review of information held on the service file, a review of the information included in the completed Annual Quality Assurance Assessment (AQAA) and a review of the updated statement of purpose and service user guide provided, a tour of the premises, a review of records, spending time talking to residents, staff and management and reviewing compliance with previous requirements. Prior to the inspection feedback surveys were received from nine residents, nine members of staff and one visiting professional. Currently the Commission do not send surveys to relatives to obtain feedback on the service and two visitors were seen during the course of the inspection. The service was well managed, good staffing levels were maintained and residents were satisfied with the service provided. The environment was well maintained and furnished and fitted to a high standard. Staff presented as committed to providing quality care and support to residents in a caring and homely setting. What the service does well: A statement of purpose and service user guide was provided for residents and prospective residents, which included information about the service. Systems were in place to meet the healthcare needs of the residents and care plans were prepared and kept under review. Residents were pleased with the quality of meals provided. The staff team worked together to meet the needs of the residents and ensure residents were treated with dignity and respect. Adequate and appropriate activities were provided. Satisfactory systems were in place to manage complaints, to ensure residents were protected from harm and to manage resident’s personal allowance. The environment was excellent, well maintained and provided a homely and relaxed atmosphere for the people who live in the home. Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 6 Staffing levels were good and ensured staff had time to spend with residents and provide care in an unhurried manner. Staff were provided with training and supervision to ensure they maintained the skills needed to fulfil their roles. Recruitment procedures were good and staff were recruited in line with regulation. The home was well managed and a satisfactory system was in place to monitor the quality of the service. Attention was given to providing a safe environment for residents and others. What has improved since the last inspection? What they could do better: 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. Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 7 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 Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 8 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): Standards 3 and 4. Standard 6 did not apply. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Satisfactory information was provided about the service for residents and residents were admitted to the home based on a pre-admission assessment of need. EVIDENCE: The statement of purpose and service user guide had been updated and copies provided to the Commission. Copies of these documents were made available to residents and prospective residents. A newsletter was provided on a regular basis and this kept residents informed about events and issues in relation to the home and the wider services of Morden College. Feedback received from residents showed that they had received adequate information about the service prior to or at the time of admission. Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 9 Pre-admission assessments were seen in the care records inspected. Residents received written confirmation that based on assessment the service was suited to meeting their needs. Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 10 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): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans were prepared to show how resident’s needs would be met. Staff supported and assisted residents to access health care services. Medicines management required some improvements. Residents said staff treated them with respect and they were satisfied with how their needs were met. EVIDENCE: Four sets of care records were inspected in total. These were well prepared and reflected how assessed needs and assessed risks were to be managed. On both floors risk assessments and care plans were reviewed monthly or when needed. Records seen included assessment in relation to moving & handling, nutrition, safety, continence, pressure ulcer prevention and skin care and personal hygiene. Also all care records seen included a mental capacity assessment. No resident had a pressure sore at this time and records in relation to other wound management included satisfactory guidance for staff. On-going wound assessment records were in place. Bed rail risk assessments were completed for residents requiring this equipment. The rise and fall beds provided came with fitted bedrails. In some instances these may not be of a Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 11 suitable height to ensure the person’s safety. The manager said that height extensions can be fitted to the rails where needed. Daily care records reflected how care was delivered. Residents spoken with confirmed they were satisfied with how their care needs were being met. Care staff spoken with said they had input into care plan preparation and had time to read and keep up to date with these. Feedback received from residents showed they were very satisfied with how their needs were met. Care records seen included dates of visits by healthcare professionals. Residents were supported to access a GP, dentist, optician, chiropodist and other healthcare professionals as needed. The provider employed a physiotherapist that helped residents with mobility, provided moving and handling training for staff and assisted staff with moving and handling assessments where needed. Residents spoken with confirmed they had access to healthcare and appreciated the input of the physiotherapist. Policies and procedures were provided in relation to medicine management and were last reviewed in 2008. Medicines were safely stored and records kept for receipt, administration and disposal. All entries on administration charts were hand written by staff but the information was not always copied exactly as on the pharmacy label and had not been countersigned. Entries made by staff on administration charts were signed by the GP but not at the same time as staff made the entry. The service was in the process of changing the medicine system to a monitored dose system and staff had received training from the supplying chemist on this. The new system will include pre-printed administration charts and this should resolve the issues in relation to staff hand writing medicines on the charts. Medicine supplies for six residents were checked. On the first floor some inaccuracies were noted. For example for all three people the remaining stock for one medicine did not tally with the amount supplied and administered and one of these people was self administering their medicines. Controlled drugs and homely remedy medicines checked on this floor were correct. On the ground floor the medicine records and supplies were checked for three people and some inaccuracies noted. For example staff had not countersigned entries they made on administration charts and one medicine supplied for one person was signed as given but the amount received was still in stock. Competency assessments were completed for staff responsible for medicine management. These were completed yearly for nurses and six-monthly for senior carers. Requirement 1. All bedrooms were for single occupancy and residents could lock their bedrooms if they wished. Residents spoken with on both floors said they were pleased with the way staff respected their privacy and dignity and this was echoed in the written feedback received by the Commission. From observation staff were courteous, inclusive and polite when addressing and interacting with residents and relatives. Staff knocked on doors before entering rooms, closed doors when giving care and spent time explaining procedures and reassuring residents. Comments made by residents included “I am getting excellent Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 12 care”, ”all staff are excellent” “I am treated with respect and dignity”. Relatives seen during the inspection were satisfied with the way staff treated residents. Cullum Welch Court DS0000058195.V373112.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): Standards 12 – 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable activities were provided and enjoyed by the residents. Residents and relatives were satisfied with the visiting arrangements, their ability to make choices and the quality of meals provided. EVIDENCE: Designated activity staff were employed and organised activities and entertainment for residents. The activity programme was displayed on both floors and included sessions such as flower arranging, quizzes, shopping trips, exercise to music and watching films on T.V. Residents had access to the college clubhouse with its range of social events and to the college mini bus to enjoy and take part in outings. Residents spoken with said they were satisfied with the activities provided. A weekly church service was held in the home and some residents chose to attend the service held in the chapel located in the college grounds. On the ground floor activities were well organised with residents enjoying fortnightly outings. A visiting librarian ensured ample and suitable reading material was available. The residential unit had a reminiscence room run by the activities persons and this was full of items to promote reminiscence. On the ground floor a carer was observed holding an exercise to music session with residents. A second group of residents were Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 14 involved in a quiz session. On the ground floor it was noted that one person who was confused had some restriction imposed by staff. A lock had been fitted to the en-suite door in their bedroom and staff said this was to prevent the person from wandering in and using toiletries inappropriately also the nurse call lead had been removed. Staff said that these steps had been taken to ensure the person’s safety. No risk assessment had been completed in relation to this and the issue was discussed with the manager. A care plan in relation to ‘decision making’ had been prepared and was kept under review. A ‘mental capacity assessment review’ was completed in September 2008 by the registered manager and concluded that the resident did not have capacity. A psycho-geriatrician and a community psychiatric nurse had also assessed the resident’s capacity in January 2008. Requirement 2. The home had an open visiting policy and a number of residents said they enjoyed and benefited from regular contact with family and friends. Visitor rooms were provided where residents could greet family and others in private. Arrangements could be made for visitors to stay overnight or to have a meal in the home. Visitors seen during the inspection said they were always made feel welcome. From observation and from talking to residents and staff it was evident that staff encouraged them to make personal choices. Staff were seen asking residents what they would like to eat, what they would like to do and offering reassurance in a calm manner to residents who needed this. Feedback from residents was very positive about the service and comments made included “staff are excellent and listen to you” and “staff are very helpful and polite”. Meals were prepared in the college main kitchens and brought to the home in heated food trolleys. The menus seen showed that residents had access to a varied and nutritious diet and the menu for the day was displayed on the dining tables. Residents were supported to choose their meal from the varied menu on a daily basis. Each floor had a kitchen where meals were served, dishes washed and snack foods and tea making facilities provided. A cleaning schedule for the kitchen was up to date and fridge temperatures were recorded daily. A number of residents commented on the high quality of meals provided. Lunch was observed and staff served this efficiently and provided residents assistance and time to enjoy the meal. Meals were a social event and residents had the opportunity to form friendships and were offered an aperitif before lunch. Cullum Welch Court DS0000058195.V373112.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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory procedures were in place to manage complaints and safeguarding adults. Staff displayed an awareness of adult protection and received training on this topic. EVIDENCE: The complaints procedure was displayed in the reception area and on each floor. The procedure included a timescale for responding to complaints and contact details for the Commission. However with the recent closure of the local Commission office this document should be updated with the new contact details. Complaint records were seen from May 07 to June 08. These included five complaints and the records showed that the complaints were managed appropriately. Residents spoken with and who provided feedback were aware of the complaints procedure and knew who to talk to if they had a concern. A policy and procedure was provided in relation to safeguarding adults. This document had been reviewed since the last inspection to clearly show that allegations or suspicions of abuse will be referred to social services for investigation. Staff spoken with displayed a good understanding of abuse and how to manage such a situation. Staff were aware of the home’s policy and whistle blowing policy in relation to safeguarding people. Training on this topic was part of the regular training programme provided for staff. Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 16 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): Standards 19, 21, 24 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The environment was clean, tidy, decorated and fitted to a high standard and was well maintained. Residents were satisfied with the personal and the communal space provided. EVIDENCE: The standard of decoration and quality furniture and fittings provided was to a high standard. The home was well maintained and no malodours noted. Grab rails were provided in corridors and by toilets. Ceiling and portable hoists were provided to ensure safe moving and handling of residents. The premises were fit for purpose and provided a comfortable and safe place for residents to live. The property had adequate assisted bathing and toilet facilities to meet the needs of the residents. Bathrooms seen met standards and were decorated in different themes and colours, which made them pleasant rooms in which to have a relaxing bath. The hot water temperatures checked in baths were Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 17 comfortable to touch and were found to be within safe limits, using the home’s water thermometer. All bedrooms had en-suites with showers, toilets and washbasins. All of these areas seen were clean, tidy and well maintained. Hoisting and bathing equipment was last serviced in July 2008. Bedrooms seen were clean and tidy and met standards. Residents spoken with said the bedrooms were always clean and tidy. Residents could bring personal items to the home and bedrooms seen had been nicely personalised with pictures, ornaments, photographs and small items of furniture. Residents spoken with were satisfied with their personal space and the communal space provided. The home was clean, tidy and odour free. Clinical waste was stored appropriately. Staff had access to infection control training, policies and procedures and alcohol gel dispensers were placed throughout the units. Staff spoken with said they were provided with adequate supplies of protective clothing. Sluice areas were provided on both floors. Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 18 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): Standards 27 – 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staffing levels were very good and the staff team had the skills to meet the needs of the residents. Staff were provided with training relevant to their work and staff recruitment procedures had improved and complied with regulation. EVIDENCE: The staff team comprised of a full time manager, a full time deputy manager, two unit managers, night sisters, trained nurses, care assistants and ancillary staff. Staff rotas seen showed that the number and mix of staff on each shift was maintained above minimum levels and staff spoken with supported this. Staff communicated appropriately with residents and presented as approachable and helpful. The home had a stable staff team, which provided continuity of care for residents and had a bank of casual staff to cover for permanent staff when needed. Staff said agency staff were not used. Feedback received from residents about the staff was complimentary and comments made included “staff are excellent”, “staff are helpful”, “staff are very pleasant” and “I am extremely happy and get excellent care”. A system was in place to check that nurses employed were registered with the Nursing & Midwifery Council and over 50 of care staff had achieved NVQ 2 qualification. Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 19 Four employee files were inspected and all contained the information required by regulation. There was evidence to show that these employees had satisfactory CRB checks. Confirmation had been obtained from the nursing & midwifery council as to the current registration of nurses employed and a system in place to monitor nurse registration Feedback received from staff was complimentary about their employment. Comments made included “I am lucky to work in such a wonderful environment”, “staffing levels are good and this enables us to have time to spend with resident” and “we get excellent training and support to do our jobs”. A full time training coordinator was employed and arranged vocational and mandatory training for staff and maintained staff training records. The training coordinator prepared a training plan for 2008. The home offered most training courses in-house and also provided training in partnership with the London Borough of Greenwich staff learning and development and the programme for 2008/09 was available to staff. The training officer said that all in-house training had assessment built-in, and staff were asked to write a summary on external courses they attend and discuss what they learned and how it would impinge on practice. Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager was registered with the Commission. A satisfactory quality assurance system was in place. Resident’s personal finances were safely managed and attention was given to providing a safe environment for residents and others. EVIDENCE: The manager had the skills, qualifications and experience needed to manage the service. Since the last inspection the manager had registered with the Commission. Staff spoken with were very satisfied with the management support provided and said that the manager was approachable and accessible. Residents spoken with knew the manager by name and said she was a regular visitor to the units. The service registration certificate and liability insurance certificate were displayed prominently in the front entrance. Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 21 Management is to be commended on the implementation of a comprehensive quality assurance system since the last inspection. Satisfaction surveys were sent to residents, relatives, visiting professionals and staff six monthly. Collated responses seen showed that overall people were satisfied with the quality of service provided. Suggestions included in survey feedback was addressed by management and included in an improvement plan. Regular meetings were held with residents and staff. Systems were in place to complete in-house audits on areas such as care planning and medicine management. Regulation 26 visits were undertaken and reports completed on a monthly basis. A number of residents managed their own finances or a family member did this on their behalf. A safe system was in place to assist residents to manage their personal allowances where needed. Individual computer records were kept and made available to residents. A safe was provided to store money and valuables for residents. The manager said that all residents had access to their personal allowance. Financial records for one resident were inspected and found to be correct. The training officer carried out supervision with staff members every two months. Supervision records were seen for two staff members and staff spoken with confirmed they received regular supervision. A random sample of documentation relating to health and safety, specifically, that for fire, controlled waste, electrical installation, water, gas safety was inspected. All records seen were up to date and equipment was serviced within appropriate timeframes. Records seen showed that attention was given to providing a safe environment for residents and others. Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 22 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 X X 4 4 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X 4 X X 4 X 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 4 Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement Hand written entries made on administration charts by staff must be countersigned and must reflect the details on the pharmacist label. Accurate records must be kept for all medicines bought into the home. Management must ensure that prescribed medicines are administered to residents according the prescription. Systems must be in place to monitor compliance with medicines for residents who choose to self-medicate. Management must ensure that risk assessments are completed prior to imposing restrictions to resident’s choice. Timescale for action 19/01/09 2 OP12 13 19/01/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 24 No. Refer to Standard Good Practice Recommendations Cullum Welch Court DS0000058195.V373112.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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