Care Home: Warrengate Nursing Home

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What the care home does well The home is clean, comfortable and well maintained. The provider is continually looking at ways to improve the home for the benefit of the residents. A visitor comment card included, `Beautiful house with lots of fresh flowers`. There is a friendly and welcoming atmosphere in the home. A visitor comment card included, `A lovely homely atmosphere, with friendly attentive staff`. Staff at the home offer care to meet individual residents needs. A health care professional comment card stated, `Caring Supportive Staff and Holistic Care`. Meals at the home are good. A visitor comment card included, `Food excellent menu and presentation with choices. Plenty of between meal snacks and drinks etc.` A visitor said, "It came well recommended". A member of staff said, "It`s a great home to work in". What has improved since the last inspection? The assessment process has been further developed to make the move into care as stress free as possible. A number of beds have been upgraded and pressure mattresses have been purchased. An activities coordinator has been appointed and activity programme has been improved. A new sensory garden has been provided and includes raised flower beds and better access for all residents. A variety of environmental improvements have been made including provision of a new `wet room` and a shower room, provision of 2 new boilers, decoration of the hallways and communal rooms, and replacement of windows, soffit board and guttering. All rooms have been equipped with televisions and the main lounge has a new flat screen television and digi box. The number of permanent staff has increased and the level of agency staff has therefore been reduced. The manager has completed her Registered Managers Award. The manager is now totally supernumerary allowing her to have a more holistic view of the home and to monitor standards more closely that when working as an allocated member of the shifts. What the care home could do better: There are no requirements made on this report. But three recommendations have been made. That residents or their representatives should be more involved in reviews of care plans. That the resident`s wishes around their death should be recorded. And that staff files are updated to meet the current requirements. CARE HOMES FOR OLDER PEOPLE Warrengate Nursing Home 2 The Warren Kingswood Surrey KT20 6PQ Lead Inspector Chris Woolf Unannounced Inspection 5th December 2007 09:55 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 Warrengate Nursing Home DS0000013367.V354124.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. Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Warrengate Nursing Home Address 2 The Warren Kingswood Surrey KT20 6PQ 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) 01737 833359 01737 833645 Claremont Care Services Limited Mrs Catherine Mary Blatcher Care Home 36 Category(ies) of Dementia - over 65 years of age (9), Old age, registration, with number not falling within any other category (36) of places Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the 36 (thirty-six) service users accommodated in the home up to 9 (nine) persons may fall within the category of Dementia (Older People) DE(E) 26th September 2006 Date of last inspection Brief Description of the Service: Warrengate is a large detached home standing in its own grounds in a residential area on the edge of a private estate in Kingswood just off the A217, some three and a half miles north of the M25. The grounds to the front of the house provide good parking for visitors and the large gardens are secluded. There is a railway station at the local village about a mile away, where there are also amenities including shops, post office and banking facilities; these can be reached by car or using the homes private mini-bus. The home provides accommodation with nursing for up to thirty-six older people and has provision within this number to support up to nine people with dementia. The current fees for the service at the time of the visit range from £550 to £850 per week. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address of the home is info@warrengate.com Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information for this report was gained from an Annual Quality Assurance Assessment (AQAA) completed by the home; Questionnaires completed by 2 residents, 3 relatives/visitors, 4 health care professionals, 1 Care Manager, and 2 staff; and a site visit to the service which lasted 6¾ hours. The site visit was unannounced which means that neither the staff nor the residents knew that it was going to happen. The site visit included talking with the majority of residents in passing and 2 in more depth; and talking with 4 visitors, a health care professional, a hairdresser, a selection of staff on duty 4 in more depth, the owners, and the manager. A tour of the building was undertaken. Observations were made of the reactions between residents and staff, and of a meal being served. A variety of records were examined and these included care plans, staff files, medication records, menus, and a selection of health and safety related records. What the service does well: What has improved since the last inspection? The assessment process has been further developed to make the move into care as stress free as possible. Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 6 A number of beds have been upgraded and pressure mattresses have been purchased. An activities coordinator has been appointed and activity programme has been improved. A new sensory garden has been provided and includes raised flower beds and better access for all residents. A variety of environmental improvements have been made including provision of a new ‘wet room’ and a shower room, provision of 2 new boilers, decoration of the hallways and communal rooms, and replacement of windows, soffit board and guttering. All rooms have been equipped with televisions and the main lounge has a new flat screen television and digi box. The number of permanent staff has increased and the level of agency staff has therefore been reduced. The manager has completed her Registered Managers Award. The manager is now totally supernumerary allowing her to have a more holistic view of the home and to monitor standards more closely that when working as an allocated member of the shifts. 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. Warrengate Nursing Home DS0000013367.V354124.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 Warrengate Nursing Home DS0000013367.V354124.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): 3. Standard 6 is not applicable in this home Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can be confident that their needs will be assessed, prior to them moving into the home. This home does not provide intermediate care beds EVIDENCE: The home updated its Statement of Purpose during the last year to more accurately reflect the services that it offers. Prior to admission to the home the manager obtains as much information about the prospective resident as possible by obtaining social worker reports and hospital assessments. She then visits the prospective resident to obtain information from them and their relatives or carers and to undertake a detailed assessment of their medical, social, religious and cultural needs. During the Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 9 year the assessment process has been further developed to make the move into care as stress free as possible. The home accepts emergency admissions from time to time, but always insist on having as much information as possible prior to the admission. Under such circumstances the care managers are required to provide information and the residents G.P. is requested to fax medical information prior to admission. The initial assessment is then undertaken on admission. Warrengate Nursing Home DS0000013367.V354124.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): 7, 8, 9, & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s health care needs are met by the home with the support of a variety of health care professionals. Resident’s dignity is respected and their privacy is protected. EVIDENCE: The home draws up a detailed plan of care for each resident based on the preadmission assessments. The initial care plan is prepared and is ready for use as soon as the resident is admitted with the exception of emergency admissions when it is prepared as soon as possible after admission. Care plans include details of physical and mental health, personal, social, equality and diversity needs. A variety of personalised risk assessments including tissue viability, falls risk, and nutrition are recorded. Care plans are reviewed regularly but there is no evidence of the involvement of the resident or their representative in these reviews apart from annual reviews with care managers. A recommendation is made regarding this. Not all care plans include details of Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 11 the resident’s wishes around death and a recommendation is also made regarding this. As this is a care home with nursing there is at least one trained nurse on duty at all times. Care staff at the home, and a multi-disciplinary health care team, supports the nurses in meeting the health care needs of the residents. Residents said, “They came to check my eyes and I am now waiting for a hospital appointment”, and “they checked my teeth and I now need to wait for an appointment at the hospital”. Visitors commented, “We are happy overall with the care”, and “The care is absolutely fabulous, just wonderful”. The home has a low incidence of pressure area sores, but whenever necessary the Tissue Viability Nurse visits to give advice. During the past year a number of beds have been upgraded and pressure mattresses have been purchased to help prevent pressure areas from developing. Relative Comment cards confirmed they feel the care home meets the needs of the resident and included the comment, ‘I thank god my loved one is there, I can rest assured she is being looked after so well’. A care manager comment card included, ‘In my experience the care home usually take appropriate action to meet health needs’, and ‘I have had some positive feedback from service user relatives about care staff meeting individual need’. On the negative side, one resident comment card stated, ‘Care service can be a bit slack with staff playing about’. The home has robust procedures for the receipt, administration, and disposal of medication. Trained nurses dispense all medication, with care staff at times assisting as second witness. Several of the nurses and care staff have attended a medication awareness course during the past year. Staff at the home treat the residents with respect and uphold their right to privacy. A visiting health professional commented, “They treat the residents with respect, very much so”. A resident said, “Staff always knock at my door, and at night I lock the door but the staff can still come in to check me”. A visitor said, “They treat them with respect”. A visitor comment card stated, ‘Visitors always get the same respect’. The home takes into account the importance of the Mental Capacity Act, and also the importance of caring for the equality and diversity needs of the residents. The home’s AQAA states, ‘Care plans hold all information that we have been able to obtain regarding spiritual requirements and personal wishes. We believe that we offer sensitive and supportive care’. The home has a number of residents with dementia and the majority of staff, including the domestics, have had training to meet the needs of these residents. Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 12 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, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to live a life that matches their needs and expectations; they are encouraged to maintain contact with family and friends; they have choices in all aspects of their daily lives; and they receive a varied and balanced diet. EVIDENCE: During the past year the home has employed an activities coordinator and the programme of activities on offer has increased. They are currently looking at how to further improve the activity provision. A resident comment card stated that the home has, ‘Pet therapy, entertainers/singers, hand massages, and activities organiser’, and a resident said, “We have entertainers come in”. Parties are held for special occasions. Staff said, “Staff sit and talk to the residents or take them for a walk”, and “I take one of the residents to Church on a Wednesday morning and we stay for tea and biscuits afterwards”. A health care professional comment card included, ‘There are regular concerts and an employed activity organiser’. Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 13 Residents are encouraged to maintain contact with their family and friends, and there is no restriction on visiting times. The home’s AQAA states ‘Our Home actively encourages residents to maintain all forms of social contact that they enjoyed before moving into our Home. We assist residents to maintain contact if requested’. A resident said, “My family visit, they are always made welcome and offered a cup of tea”. Visitors commented, “I look forward to coming, there is a lovely atmosphere here”, and “Some of our relatives are coming to the Christmas Party”. A staff member said, “Visitors can come when they like, we always make them welcome and offer a cup of tea”. Residents are given choices in all aspects of their daily lives. The home’s AQAA states, ‘We record where possible residents wishes regarding attendance at religious services, any cultural needs they may have and their wishes should they become ill or in the event of their death and support they require. Where residents have difficulty expressing themselves we consult with their family or representative. We seek to satisfy the spiritual needs of our residents and for example had a Harvest Festival recently’. Two different hairdressers visit the home each week thus increasing the choice for residents. The meals at the home are, nutritious, wholesome, and balanced. A visitor comment card stated, ‘The food they receive is as good as it gets, not just one day but every day’. There are two dining rooms one is used by those residents who are more able to help themselves and the other for the residents who need more assistance. Some residents choose to eat in their rooms or in the lounges. Staff assist with mealtimes in a sensitive manner. When visitors wish to help they are encouraged to assist their relatives with meals. Visitors comments included, “I help mum with her lunch”, and “Fabulous food, hotel quality, always a choice of puddings”. A member of staff said, “The food always looks nice but the packet soup at supper time is not so good as the rest”. The cook confirmed that he had tried making homemade soups but only a few residents only ate these and he therefore uses the time to make other homemade foods such as the cakes that are enjoyed by residents at afternoon tea time daily. Resident’s birthdays are always marked with a homemade cake. The home operate a 4 week menu, and choices are always available although lunchtime these are on request and not shown on the menu. Special diets are catered for as and when necessary and a staff member said, and “We have one person on a gluten free diet”. A health care professional commented, “The food is nice, and varied. They are given as many drinks as possible”. Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 14 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, & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their concerns and complaints will be listened to and acted upon and that they will be protected from abuse. EVIDENCE: The home has a simple, clear and accessible complaints procedure and comment cards completed by residents and visitors confirmed that they know how to make a complaint if necessary. One resident card said, ‘Talk to matron’. Visitor comment cards confirmed that the care service had responded appropriately when concerns had been raised. The home has had 2 complaints during the past year. One of these was raised with the Social Care team who forwarded it to the home for investigation. Both complaints have been dealt with satisfactorily. Residents are protected from abuse. The home follows the Surrey Safeguarding Vulnerable Adults guidelines. There is a whistleblowing policy in place. All new members of staff are checked against the Protection of Vulnerable Adults register before they start working in the home. Foreign workers are checked against their own country’s criminal records. All staff receive training about the protection of vulnerable adults. Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 15 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, 24, & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is clean, comfortable, and well maintained, with bedrooms that are personalised to meet their needs. EVIDENCE: The home is set out over 2 floors with a lift to give access to the upper floor. The premises are well maintained and meet residents’ needs in a comfortable and homely way. A florist visits weekly to provide fresh flowers for the porch, hall, and library. A variety of improvements have been made during the past year including provision of a new wet room, a new shower room, fitting of 2 new boilers, decoration of the hallways and communal rooms, and replacement of windows, soffit board and guttering. Improvements have also been made to the garden area and a new sensory garden has been provided with raised Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 16 flowerbeds and raised pond. Ramped access is being provided from the lounge to ensure that all residents will be able to enjoy this facility. The home has 2 large lounge/dining areas and a separate library. This ensures a variety of places for residents to sit and also to meet visitors in private if they so wish. The chairs in the dining area are fitted with ‘skis’ to enable residents to be moved more easily. A new larger flat screen television has recently been provided in the main lounge. Resident’s bedrooms are personalised to meet their individual needs. During the last year all bedrooms have been provided with televisions. Residents commented, “I’m quite comfortable in my room”, “I have a lockable drawer”, and “Those are my family photos”. Where rooms are used for shared occupancy there are either curtains or screens available to allow personal care tasks to be carried out in privacy. The home is kept clean and odour free and appropriate infection control policies and procedures are in place. A resident comment card included, ‘Quite clean, happy with standard of cleanliness’. Visitors said, “Its always clean”, and “No odours”. Staff commented, “It’s kept clean and usually odour free” and “The cleanliness is good, the domestics do a fantastic job, they are both very hard working”. Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 17 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, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A team of properly recruited staff, who are trained to meet their needs, cares for residents. EVIDENCE: The home employs sufficient staff to meet the assessed needs of the residents. Permanent staffing levels have been increased and this has reduced the need to use agency staff. A health care professional commented, “There are enough staff to cover for most things”, and a staff comment card included, ‘I find the staffing levels exceptionally good’. However, one staff member said, “Some staff don’t pull their weight, just talk a lot”. As this could affect staff morale the manager is urged to monitor this and take appropriate action. 50 of the care staff have attained NVQ at Level 2 or above. A further 3 are working towards this qualification; one is about to start NVQ Level 3; and the two housekeepers are about to start the NVQ level 2 in housekeeping. A staff member said, “I am starting my NVQ 3”. The home operates robust recruitment procedures. No new member of staff starts work until an enhanced disclosure has been submitted to the Criminal Records Bureau, a satisfactory check has been obtained of the Protection of Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 18 Vulnerable Adults register, and two satisfactory references have been received. Where staff are brought in from overseas the checks are carried out by the recruitment agency and include a check on the police records from the staff members home country. The ‘pin’ number of all registered nurses is checked against the records of the Nursing and Midwifery Council. At present the home does not hold a full employment history for each member of staff and a recommendation is made that staff files should be updated to meet the requirements of the revised Schedule 2 of the regulations. All staff are issued with the General Social Care Council Code of Conduct, and the booklet Working safely. All new members of staff have induction training to Skills for Care specifications. A staff comment card included, ‘ The manager took a lot of time inducting me in my role’. The home is actively working towards getting all of the staff up to date with statutory training; currently there are just a few gaps. During the past year in addition to the statutory training 8 staff have undertaken medication awareness training, and 1 has attended Palliative Care training. The home has also started to use the Mental Capacity Act 2005 Residential Accommodation Training Set from the Department of Health. Comment cards included the following statements about staff. A relative card said, ‘I always find the staff very loving and caring and polite to all its residents at all times. They all do their best to make everybody comfortable and happy’. A health care professional card stated, ‘Friendly and happy staff with good contact skills with residents’. A Care Manager card said, ‘My experience of the staff has been good. They appear to be skilled in their work’. Comments made on the day of the site visit included a visiting professional who said, “The staff are amenable. Very responsive to residents needs”. A resident said, “The staff on the whole are kind and gentle”. Visitors said, “The staff are absolutely lovely, they all get on well together”, and “They keep the same staff, they are really friendly”. A member of staff said, “Its a great home to work in”. Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the residents. The health, safety and welfare of residents and staff are protected. EVIDENCE: The Registered Manager is a Diploma nurse and she has completed her Registered Managers Award during the past year. Her hours are now totally supernumerary allowing her to have a more holistic view of what is going on in the home without being bogged down in running shifts. She still does some hands on nursing when necessary, and is available to help when needed. She regularly updates her own knowledge and practice and has recently attended training on the Mental Capacity Act. Comment cards included the following Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 20 about the Manager. Staff, ‘I find her (the manager) very approachable and knowledgeable’, and a relative ‘It is very well run by Cathy Blatcher (Manager). I am very happy the way it is and hope it stays like that always’. Comments on the day of the site visit included a resident who said, “Cathy always comes to say good morning”; a visiting professional said, “Cathy is one of the best, she attends to problems straight away”; and visitors said, “Cathy is very good. She cares for the staff as much as the residents”, and “Cathy runs a tight shift but they are all happy”. The provider is also in daily contact, and is very involved in the running of the home. On the day of the site visit he was busy in the home and garden all day and was observed to have a very good manner and rapport with the residents. The home has developed its own Quality Assurance systems and the next batch of questionnaires were due for distribution but have been held back until after Christmas as the Commissions questionnaires have only recently been distributed. It is intended to include surveys to visiting professionals with the next circulation, and the home are going to introduce staff surveys next year. The home are also planning to produce an analysis of results of the surveys and these will be made available to stakeholders. The manager carries out a variety of regular audits. The home does not have a documented development plan as this is mainly in the provider’s head and he is always looking at areas that can be improved. He is encouraged to produce a documented development plan to give more structure to his plans. The home does not hold any cash for their residents. Any transactions, such as chiropody and hairdressing, is paid for by the home and then invoiced to the resident’s family or representative. The health safety and welfare of residents and staff are protected. Staff undertake statutory health and safety related training. Accident, safety, and servicing records are in order. Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 21 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard OP7 OP7 OP29 Good Practice Recommendations Residents or their representatives should be involved in the reviews of the care plans. Care plans should include details of the residents’ wishes regarding procedures at the time of their death. Staff files should be updated to meet the requirements of the revised Schedule 2 of the Care Homes Regulations. Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection South East Regional Contact Team The Oast Hermitage Court Hermitage Lane Maidstone, Kent ME16 9NT 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 Warrengate Nursing Home DS0000013367.V354124.R01.S.doc Version 5.2 Page 24 - 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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