Care Home: Walliscote Manor

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What the care home does well Walliscote Manor provides homely well-maintained accommodation for people requiring personal care. This is carried out in a respectful way that takes into account their right to maintain personal choice and control over the way they live. People living in Walliscote manor who wished to talk about their experiences said they were very happy with the care and support they received from the staff in the home. They said they felt they could keep control over their lives but also get the care they needed that prevented them living in their own home. Comments received said that staff were very caring and considerate. One relative said that they were more than happy with the standard of care provide and wished to thank the staff for their attention to detail.One person living in the home said they were helped to do the things they wanted to do. The people who commented on their lives at Walliscote Manor especially enjoyed the activities now provided. Especially the provision of a computer game, that enables them to take part in sports and memory games. Staff members said that they felt the atmosphere of the home was caring and happy which made all the difference. They stated that they felt supported by the manager and able to contribute to the way care is provided. What has improved since the last inspection? This is the first inspection since the home was taken over by Alutrarius. People living in the home have said that the activities provided have improved. What the care home could do better: Following this inspection and a review of the evidence gathered before and after our visit we have made 2 requirements and 5 recommendations. We asked for a copy of the Statement of Purpose and Service User Guide. These were not available in the home and should be produced on request. The area manager said that Alutarius was reviewing the documentation. The Statement of Purpose and Service User Guide must be available in the home. All residents need to have a copy of the service user guide as it will give them the information about the home that they need to know. People living in the home did not have up to date contracts with Alutarius. We were told these were being looked at and would be made available for residents to sign shortly. All residents must have a contract or statement of terms and conditions setting out the rights and responsibilities of both the residents and the home. Many of the residents in Walliscote Manor could discuss the care they received and the way it was delivered. Care plans did not show that they had been agreed with the resident. Care plans need to be signed by residents to show the way care is provided has been discussed with them. The policy and procedure for safeguarding adults needs to be reviewed to come in line with the local No Secrets policy and procedure.One downstairs toilet has a carpeted floor that is looking stained and worn. The providers need to provide non-permeable flooring to prevent cross infection and bad odours. Access to the home is up a flight of steps a removable ramp is used but still makes the slope very steep and difficult to negotiate. The providers need to look at ways to improve disabled access to the home. Policies and procedures looked at were out of date and some did not reflect Walliscote Manor as they had been taken from another care home. The providers need to review all policies and procedures used in the home. CARE HOMES FOR OLDER PEOPLE Walliscote Manor 7 Walliscote Road Weston Super Mare North Somerset BS23 1XE Lead Inspector Juanita Glass Unannounced Inspection 21st April 2008 09:30 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 Walliscote Manor DS0000070928.V360989.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. Walliscote Manor DS0000070928.V360989.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Walliscote Manor Address 7 Walliscote Road Weston Super Mare North Somerset BS23 1XE 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) 01934 635363 01934 621840 Alutarius Ltd Mrs Jennifer Way Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Walliscote Manor DS0000070928.V360989.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 providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category - (Code OP) The maximum number of service users who can be accommodated is 16. Date of last inspection Brief Description of the Service: Walliscote Manor is a converted Victorian House close to the main shopping centre and a short walk from the beach. It is registered to provide personal care to up to 16 people over the age of 50 years. They aim to provide a high standard of care in a homely atmosphere. They do not offer nursing care but receive support from the local GP practice. People living in the home are supported to remain as independent as possible. They have access to private single bedrooms which they can personalise to reflect their life or interest. Walliscote Manor DS0000070928.V360989.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 2 star. This means the people who use this service experience good quality outcomes. This inspection took place over two days in the presence of the manager Mrs Jennifer Way. A total of 7 hours were spent in the home. Evidence to support the findings of this inspection was obtained through written surveys from people living in the home and their relatives. Reponses to our written survey were received from 11 people living in the home, 4 relatives, 9 members of staff and 1 social worker. An Annual Quality Assurance Assessment (AQAA) was completed by the homeowner and forwarded to the Commission for Social Care Inspection (CSCI). We also carried out a review of documentation in the home. This included documentation in peoples care plans, staff personnel records and records maintained for the day-to-day running of the home. Whilst in Walliscote Manor we discussed the care provided with 6 people living there on a one to one basis and as a group. We also spoke to 2 staff members working on the day of the inspection. What the service does well: Walliscote Manor provides homely well-maintained accommodation for people requiring personal care. This is carried out in a respectful way that takes into account their right to maintain personal choice and control over the way they live. People living in Walliscote manor who wished to talk about their experiences said they were very happy with the care and support they received from the staff in the home. They said they felt they could keep control over their lives but also get the care they needed that prevented them living in their own home. Comments received said that staff were very caring and considerate. One relative said that they were more than happy with the standard of care provide and wished to thank the staff for their attention to detail. Walliscote Manor DS0000070928.V360989.R01.S.doc Version 5.2 Page 6 One person living in the home said they were helped to do the things they wanted to do. The people who commented on their lives at Walliscote Manor especially enjoyed the activities now provided. Especially the provision of a computer game, that enables them to take part in sports and memory games. Staff members said that they felt the atmosphere of the home was caring and happy which made all the difference. They stated that they felt supported by the manager and able to contribute to the way care is provided. What has improved since the last inspection? What they could do better: Following this inspection and a review of the evidence gathered before and after our visit we have made 2 requirements and 5 recommendations. We asked for a copy of the Statement of Purpose and Service User Guide. These were not available in the home and should be produced on request. The area manager said that Alutarius was reviewing the documentation. The Statement of Purpose and Service User Guide must be available in the home. All residents need to have a copy of the service user guide as it will give them the information about the home that they need to know. People living in the home did not have up to date contracts with Alutarius. We were told these were being looked at and would be made available for residents to sign shortly. All residents must have a contract or statement of terms and conditions setting out the rights and responsibilities of both the residents and the home. Many of the residents in Walliscote Manor could discuss the care they received and the way it was delivered. Care plans did not show that they had been agreed with the resident. Care plans need to be signed by residents to show the way care is provided has been discussed with them. The policy and procedure for safeguarding adults needs to be reviewed to come in line with the local No Secrets policy and procedure. Walliscote Manor DS0000070928.V360989.R01.S.doc Version 5.2 Page 7 One downstairs toilet has a carpeted floor that is looking stained and worn. The providers need to provide non-permeable flooring to prevent cross infection and bad odours. Access to the home is up a flight of steps a removable ramp is used but still makes the slope very steep and difficult to negotiate. The providers need to look at ways to improve disabled access to the home. Policies and procedures looked at were out of date and some did not reflect Walliscote Manor as they had been taken from another care home. The providers need to review all policies and procedures used in the home. 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. Walliscote Manor DS0000070928.V360989.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 Walliscote Manor DS0000070928.V360989.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, 2, 3, 4 and 5. 6 does not apply Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People intending to move into Walliscote Manor could benefit from plenty of up to date information to help them make an informed choice. However this information is not available on request in the home. People can visit the home before making a final choice to move in and have a four week trial period to get to know the home and other residents. They are not offered a place unless the manager is happy the home can meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide were not available when we asked for it at the inspection. The area manager said that Alutarius was reviewing what they would put in both the guides. These would give people information about the home and the care they would expect to receive. Walliscote Manor DS0000070928.V360989.R01.S.doc Version 5.2 Page 10 Without his information people will not know whether the home can meet their needs. People looking for a care home will receive plenty of very clear information to help them make the choice when the documents are reviewed and available in the home. We asked if any resident had a Contract or Statement of Terms and Conditions with the new owners. We saw the old contracts but Alutarius has not drawn up any agreement with the current resident group. People living in the home need a signed agreement so they know what rights and responsibilities both they and the home have regarding the care and accommodation provided. We looked at the care plans for five people living in the home; these included the care plans for people who had moved in after it was taken over by new ownership. We found that all care plans contained a very full pre admission assessment. This means people were not offered a place unless the manager was sure the home could look after them the way they preferred. Whilst looking at the home people were also offered a chance to visit and meet other residents and staff. If they decide that Walliscote Manor was the right home for them they were also offered a trial period of four weeks. This gave them and the staff in the home the chance to be sure that they are going to be happy living there and the home is going to be able to look after them. The surveys we received from people living in the home showed that they were unsure whether they had a contract or not. Most people said they felt they had plenty of information. However most people spoken to had been living in the home for a few years. Walliscote Manor DS0000070928.V360989.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, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from care plans that are easy to read and understand this helps them receive a good standard of care. They are written in a person centred way, which reflects, peoples personal preferences. People are also helped to see health care professionals and the service provided respects peoples right to equality, privacy and dignity. They are also protected by clear policies and procedures for the Administration of Medication which staff follow very closely. EVIDENCE: We looked at the care plans for five people living in Walliscote Manor we also spoke to people living in the home. People said the care they received was good. They said they felt very well looked after and the staff was caring and considerate. Surveys said that the level of care was good from a committed and trained team of staff. Relatives said that they were pleased with the care provided. Walliscote Manor DS0000070928.V360989.R01.S.doc Version 5.2 Page 12 The way people are looked after is person centred and takes into account how people want to be looked after. With their personal likes and dislikes identified. One member of staff said that better life histories would give them a clearer view of who the person was but felt that care records were informative and well maintained. Written care plans reflected the level of personal choice that people were seen to enjoy in the home. The care plans did not show that people living in the home had read them and signed to say they agreed with the care being provided. People spoken to were aware of the care they needed and would benefit from having a say in the way that care is provided. Staff spoken to knew about people’s personal preferences and could talk about the care people were being given. They also said that they were kept up to date with the way people liked to be looked after. Staff surveys said communication was generally good with very good handovers where they would share their information. However one member of staff stated in their survey that there were rare occasions when communication slipped and changes were not recorded. The care plans we looked at showed that people living in the home were given a lot of support to continue to see health care professionals, such as support from district nurses for pressure area care and from the Mental Health Team. They received regular visits or attended regular appointments with the chiropodist, dentist and optician when they needed to and they were also helped to attend hospital appointments. People we spoke to said that they felt staff treated them with respect. One gentleman said that they were very nice people and he always got on very well with them. Another gentleman spent much of the day chatting and joking with staff and said they were good, respecting his individual needs. Staff also knew that they might need to take cultural differences into consideration. This had been considered in relation to one person’s religion and all the information and support needed was in place. We looked at the way medication was kept and given to people. We looked at the charts staff sign and we found no errors. Medication was stored properly and they had an extra safe place for storing controlled drugs. A medication trolley is provided and staff were seen giving medication in the proper way. They did the medication round together and charts showed that there were always two signatures for all medicine given. This is very good practice and protects people from mistakes. We talked to the manager about respecting peoples end of life wishes. She was in the process of setting up advance directives with the people living in the home who wished to say what they would prefer. This is good practice and we will look at how this has been provided at our next visit. Walliscote Manor DS0000070928.V360989.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. There has been an improvement in the provision of activities in the home people are now offered a daily activities programme. People can access their local community and see family and friends with support from staff. People exercise control over the way they prefer to live. People living in the home are offered a balanced and healthy diet. They can choose what they want to eat and staff respect their personal likes, dislikes and cultural backgrounds. EVIDENCE: The manager has introduced a programme of activities to people living in the home. People we spoke to said they had plenty to do if they choose to. One gentleman said he had plenty to do and thoroughly enjoyed the quizzes and memory games. One lady said she enjoyed being able to play virtual sports on the computer game provided. Several residents sat in the lounge agreed that they enjoyed the Brain Training games that they did in the evenings. Walliscote Manor DS0000070928.V360989.R01.S.doc Version 5.2 Page 14 People living at Walliscote Manor like to choose how they spend their day; care plans showed that they often went into town or went for a walk. One care plan showed that religious observance was important for one person and the staff had supported them to attend services. Then they were assisted to receive pastoral care when they were too ill to attend church. Two staff surveys said it would be nice if residents could go out on organised trips more often, one suggested the home purchase their own minibus to make this possible. People living in the home said they thought the staff helped them lead the kind of life they would prefer. They said they were helped to keep in touch with their friends and family. We looked at the menu that was in the home. It showed that people are offered a choice. We saw the choices people had when we joined them for lunch. The meal was well presented and nutritious with ample portions. The mealtime was relaxed and cheerful with residents chatting and joking with staff. One gentleman said he always had a very nice meal and if there was something on the menu he did not like staff would find something else for him. When we spoke to the person in the kitchen they said they knew what people liked and they knew who had to have a special diet. Walliscote Manor DS0000070928.V360989.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): 16, 17, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are protected by the manager’s knowledge of the procedure to follow. However the policies and procedures do not reflect the local No Secrets procedures. People are supported in registering to vote in local and general elections if they wish. People are enabled to raise concerns or issues as they have access to a very clear complaints policy and procedure. EVIDENCE: The homes policy and procedure for Safeguarding Adults was not very clear. It was dated and did not reflect the procedure to be followed in the event of a safeguarding issue. We discussed this with the manager and we were satisfied that the manager had a very clear knowledge of the correct procedures to follow. She had dealt with a potential safeguarding issue properly doing everything right. She had informed all the people who needed to be contacted. Walliscote Manor DS0000070928.V360989.R01.S.doc Version 5.2 Page 16 Residents can take part in local and general elections and will receive support from staff to do so. Either by registering for a postal vote or attending personally People spoken to said they knew how to make a complaint if they wanted to. They said they could approach the manager and staff and not be afraid to say something was wrong. One gentleman said he could bring things up at residents meetings or go personally to the manager. Everybody spoken to knew they could contact their social worker or CSCI. Walliscote Manor DS0000070928.V360989.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): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in Walliscote Manor benefit from a comfortable, safe and homely atmosphere, in a home that is clean tidy and well maintained. They have comfortable bedrooms with their own possessions. Special aids and adaptations can be provided. EVIDENCE: We walked around Walliscote Manor looking at the way the home is maintained and we asked if we could look in two private rooms. We also talked to people about their rooms and what they liked about the home. Walliscote Manor DS0000070928.V360989.R01.S.doc Version 5.2 Page 18 People said they liked the home as it was and that it felt homely and was their space. One gentleman showed us his room and said it was just what he needed with the right level of personal processions for him. He had photographs and pictures that reflected his personal life. We looked in another room and commented on the old carpet, which was stained. The resident said he preferred it that way and would worry about new carpet, he said the room was his and staff respected his right to privacy when he wanted to spend time there. Both gentlemen had a key to their door. We noted that the home does need some redecoration in places but the organisation are tackling each area separately and as rooms become free. One downstairs toilet had carpet on the floor which was worn and stained we have recommended that this is replaced as it could cause problems with cross infection and unpleasant odours. If people need aids and adaptations fitted to the home or their room, they are assessed by the manager and put in place. We discussed the access to the home. This is up a steep flight of steps. A removable ramp is available but it still means that access is up a very steep slope. This could prevent a resident coming and going freely if they had a mobility issue. It could also prevent a resident from receiving a visitor who may find access to the home difficult. Walliscote Manor DS0000070928.V360989.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): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are enough staff with the right skills working at Walliscote Manor to be able to care for the people there in the way they prefer. People living there benefit from staff who receive training about the special needs they might have. This includes the needs of people with Mental Health Issues. People living in Walliscote Manor are protected from possible abuse by the way the home employs staff. EVIDENCE: We looked at the rota that tells us how many staff are working at any one time in Walliscote Manor. We saw that there are enough staff in the home to care for people in the way they would prefer. People we spoke to said there was always enough staff. We watched staff working and they had time to spend with people talking about the day or the news. Staff surveys said that since the employment of new staff there are plenty of staff in the home. Walliscote Manor DS0000070928.V360989.R01.S.doc Version 5.2 Page 20 The owner has provided training for staff so they are all up to date with training they have to do by law (mandatory training). We saw dates advertised for staff about other training that had been booked for them to go on. They have also attended training about things that are special to people living in the home, like looking after someone with Mental Health problems like Schizophrenia. Staff have also been doing the NVQ Level 2 and 3 In Health Care which means they have been learning the right way to look after people. They do not have the required 50 yet but will exceed this when staff completes the course. We looked at the records kept by the home when they employ a new member of staff. These showed that the manager was getting the right information before letting new staff work in Walliscote Manor. We saw two references, a POVA 1st and a CRB for all three people recently employed. They did not start work until the manager had these documents. This means people living in the home are protected from the possibility of harm or abuse. We also saw that new staff follows an induction and work alongside other staff so they can get a proper understanding of the way people prefer to be looked after. One member of staff felt the induction could have been more in depth others said they had enough information. Walliscote Manor DS0000070928.V360989.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, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Walliscote Manor benefit from safe management practices so they are protected from potential harm or abuse. They benefit from a manager who is experienced and qualified to run the home. Their opinions are sort about how the home is run. Their financial interests are safeguarded. They benefit from staff who are properly supervised. People in the home do not benefit from up to date policies and procedures, which are not relevant to the home. They are protected by the way health a safety is managed by staff. Walliscote Manor DS0000070928.V360989.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager of Walliscote Manor has 15 years experience in care in the community she has completed the registration process with CSCI and is an NVQ assessor. Staff surveys said they found the manager very approachable and supported them with training. They felt they were listened to and helped to meet the care needs of the people living in Walliscote Manor in a caring and compassionate way. People living in the home said they felt that there had been good changes. They felt that they were listened to and things they said were done. One person said they had been asked about activities and had said what they thought. Everybody spoken to said they thought they could talk openly to the manager. We were told that a Quality Assurance process, this is when the owners ask for people’s opinions and views of the way the home is run, will take place in the near future. This will be reviewed and a plan of action made. We also saw that the manager carries out a regular assessment of the way the home has met the National Minimum Standards set down by the Care Standards Act. We will look at the results for this the next time we visit. People living in the home are encouraged to look after their own finances. When someone asks the home to look after his or her money very clear guidelines are in place and an audit is kept of all money going out and coming in. Staff supervision is carried out 4 weekly. Staff surveys said that they felt this was a very helpful and supportive process. One survey said ‘I feel the supervision is very helpful.’ They said they felt they had plenty of support and training. They said they could talk to the manager at any time. We looked at the policies and procedure s that are kept to enable the smooth and efficient running of the home. We saw that they had not been reviewed for a few years and some of them were from other care homes, so did not reflect Walliscote Manor. The manager said these were the policies and procedures inherited when the home was bought by Alutarius. We saw a sample of policies and procedures already reviewed and replace d by Alutarius. They need to review all the policies and procedure so residents are protected by smooth and efficient practices. All areas of health and safety in the home were good. We looked at risk assessments and records that showed all the tests and maintenance that should be done was being carried out. We looked at the way the home makes sure the people living there are protected from fire. All the records were up to date and showed that staff had attended training and practiced. Walliscote Manor DS0000070928.V360989.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 2 1 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 3 3 2 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 2 3 Walliscote Manor DS0000070928.V360989.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 OP1 Regulation 4(1 & 2) 5(1 & 2) Requirement The registered person must produce and make available to service users and CSCI an up-todate statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home. And provide a service users’ guide to the home for current and prospective residents. This is so residents and prospective residents have all the information about how the home is run and how the care they receive will be provided. 2 OP2 5 (1B) The registered person must provide all residents with a statement of terms and conditions or contract if private. This is to ensure that there is a written agreement with the resident setting out the rights and responsibilities of both the resident and the home. 12/06/08 Timescale for action 12/06/08 Walliscote Manor DS0000070928.V360989.R01.S.doc Version 5.2 Page 25 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 OP7 Good Practice Recommendations The manager needs to agree the content of care plans with residents who then sign to show they have discussed the way they would prefer their care to be provided. This is to support people in receiving the care they would prefer. The policy and procedure for Safeguarding Adults needs to be reviewed to reflect the North Somerset No Secrets Policy and procedure. This to protect people from potential mismanagement of a safeguarding issue. The registered person needs to look at ways of improving disabled access to the home. This is to ensure people with mobility issues can use the front door. And people living in the home are not denied visits from disabled relatives. The registered person needs to replace the worn and stained carpet in the downstairs toilet with non-permeable flooring. This is to protect residents, staff and visitors from Cross Infection and unpleasant odours. The registered person needs to review all policies and procedures maintained by the home. This is to ensure people benefit from the smooth and efficient running of the home. 2 OP16 3 OP22 4 OP26 5 OP37 Walliscote Manor DS0000070928.V360989.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Walliscote Manor DS0000070928.V360989.R01.S.doc Version 5.2 Page 27 - 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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