Care Home: WCS - Four Ways

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What the care home does well There is good information for staff on assessments done before people move into the home. This allows staff to commence the care plan from the first day and provide the most appropriate care. Staff spend time collecting information for life histories as well as how people would like their daily care to be provided so that they can maintain some independence and are involved in how their care is to be given.The care planning system in use allows the manager to assess the abilities of people on each floor she can then make sure that the staffing levels meet the needs of the people in occupancy. There continues to be good arrangements are in place for reviewing people`s care plans on a monthly basis and review meetings take place with families to ensure they are involved in the care of their relative and the home can consider any concerns families may have. The home is open to suggestions form people living at the home and visitors, the complaints procedure is easily accessible. The home has a flexible visiting policy and service users are able to receive visits from friends and relatives at times that are convenient to them. Staff are well trained and have the skills to meet the needs of the people they care for. There are good systems in place to support quality monitoring in the home. This includes books on each floor to record any suggestions, compliments or concerns. Records showed that these are regularly used and comments are taken seriously and acted upon as appropriate to ensure the contentment and wellbeing of people. The health and safety policies and processes protect people living and working at the home. What has improved since the last inspection? The scoring system on the care plans needs to be is defined in the care plan so that staff know what care need it is they have to address. A review of medication has been done this makes sure that staff are administering medications correctly and are maintaining accurate records to safeguard people. Social activities have been reviewed and include people`s views this make sure people feel sufficiently stimulated to maintain their wellbeing. The Registered Provider completes a monthly report on the conduct of the care home to demonstrate the home is being regularly audited to confirm compliance with care standards and regulations. Food needs are now stored appropriately in kitchenettes and probed to check temperatures so this is suitable for people. Fridge temperatures within the kitchenettes are now recorded consistently to show these are operating within safe guidelines to store food. What the care home could do better: The manager needs to make sure that people who have short term memory loss and exhibit challenging behaviour are assessed regularly to make sure their needs are being met within the conditions of the registration. The cleanliness of the home is in need of attention in particular in regard to the fire escape, assisted shower rooms and commodes. All substances hazardous to health such as cleaning materials must be stored in accordance with good practice regulations (COSHH). Systems must be in place to make sure that all people requiring assistance at meal times are given this. Where staff are assisting with meals they should either eat after they have finished or eat with people as part of normal interaction. CARE HOMES FOR OLDER PEOPLE WCS - Four Ways Mason Avenue Lillington Leamington Spa Warwickshire CV32 7PE Lead Inspector Ashley Fawthrop Key Unannounced Inspection 31st March 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 WCS - Four Ways DS0000004265.V361563.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. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service WCS - Four Ways Address Mason Avenue Lillington Leamington Spa Warwickshire CV32 7PE 01926 421309 01926 882034 admin@wcsfourways.f9.co.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) Warwickshire Care Services Limited Mrs Pearl Mackey Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager must undertake the Registered Managers Award by 30th April 2007 5th March 2007 Date of last inspection Brief Description of the Service: Four Ways is managed by Warwickshire Care Services who have managed the home since it transferred along with a number of other homes providing care from Warwickshire County Council in 1992. Warwickshire Care Services are a voluntary sector organization. Four Ways is registered as a care home providing personal care to older people, including two beds, which are used for respite/short stay. The home also caters for up to eight-day care users from Tuesday to Friday inclusive. Accommodation is over three floors, there is a lounge/dining area upon each floor, 18 bedrooms have en suite facilities. There is a shaft lift to enable residents to access all floors and there is wheelchair access to the garden area. The home is situated in Lillington, which is just outside of Leamington Spa. A regular bus service into Leamington stops nearby. Local amenities such as shops are also located close by. Car parking is provided to the front and side of the building. At the time of this inspection the fees ranged from £345.00 per week to £395. Extra charges over and above the fees are made for hairdressing (from £7.00), chiropody (£12.00), newspapers, toiletries and sometimes for transport. WCS - Four Ways DS0000004265.V361563.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 stars. This means that people using this service experience good quality outcomes. The inspection was carried out without prior notification and was conducted by one inspector over the course of one day. The inspector would like to thank everyone who took the time to talk to them and express their views. Before the visit, accumulated information about the home was reviewed. This included looking at the number of reported accidents and incidents and reports from other agencies, i.e., the Environmental Health Officer, and correspondence following the last inspection. This information was used to plan this inspection visit. The inspector case tracked four people’s care plans. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of people who live in the home and staff were considered. Using this method, the inspectors assessed all twenty-one key standards from the Care Homes for Older People National Minimum Standards, plus other standards relevant to the visit. The inspectors spoke with identified people who live at the home and relevant members of the staff team who provide support to them. Documentation relating to these people was looked at. What the service does well: There is good information for staff on assessments done before people move into the home. This allows staff to commence the care plan from the first day and provide the most appropriate care. Staff spend time collecting information for life histories as well as how people would like their daily care to be provided so that they can maintain some independence and are involved in how their care is to be given. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 6 The care planning system in use allows the manager to assess the abilities of people on each floor she can then make sure that the staffing levels meet the needs of the people in occupancy. There continues to be good arrangements are in place for reviewing people’s care plans on a monthly basis and review meetings take place with families to ensure they are involved in the care of their relative and the home can consider any concerns families may have. The home is open to suggestions form people living at the home and visitors, the complaints procedure is easily accessible. The home has a flexible visiting policy and service users are able to receive visits from friends and relatives at times that are convenient to them. Staff are well trained and have the skills to meet the needs of the people they care for. There are good systems in place to support quality monitoring in the home. This includes books on each floor to record any suggestions, compliments or concerns. Records showed that these are regularly used and comments are taken seriously and acted upon as appropriate to ensure the contentment and wellbeing of people. The health and safety policies and processes protect people living and working at the home. What has improved since the last inspection? The scoring system on the care plans needs to be is defined in the care plan so that staff know what care need it is they have to address. A review of medication has been done this makes sure that staff are administering medications correctly and are maintaining accurate records to safeguard people. Social activities have been reviewed and include people’s views this make sure people feel sufficiently stimulated to maintain their wellbeing. The Registered Provider completes a monthly report on the conduct of the care home to demonstrate the home is being regularly audited to confirm compliance with care standards and regulations. Food needs are now stored appropriately in kitchenettes and probed to check temperatures so this is suitable for people. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 7 Fridge temperatures within the kitchenettes are now recorded consistently to show these are operating within safe guidelines to store food. 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. WCS - Four Ways DS0000004265.V361563.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 WCS - Four Ways DS0000004265.V361563.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): 3, 4 and 6 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who have chosen to move into the home have their needs assessed before they move in. This makes sure that staff have up to date information to start the care plan. People have the opportunity to visit the home and speak to the staff. This gives people information as to whether the home meets their needs. EVIDENCE: Assessments before people move into the home are included as part of the care plans. The assessments are done by senior staff and include people’s individual needs including physical, psychological and social needs. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 10 Staff on the unit where the person is to live then uses this information to prepare the care plan before the person moves in. Staff are then prepared to give the best care from day one. People said that they had the opportunity to visit the home before they move in. People visiting also confirmed that they had looked around the home before they chose to use the service. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health, social and personal needs are met. Medications are administrated and recorded safely and people feel they and their families are treat with care and respect. EVIDENCE: Care plans are in place for person and covered a wide range of needs and provided suitable information so that staff had the opportunity to give good personal and healthcare support. Review notes were seen on people’s files as evidence that their needs are being periodically reviewed with the involvement of the individual, social workers and relatives. People said they liked the home and were looked after well. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 12 The home is registered to care for people who are frail due to age with no special needs other than this. However, there are a number of people living in the home who are suffering from short term memory loss and do display challenging behaviour on occasions. The home must regularly re assess the needs of these people to make sure they are meeting there needs appropriately Care plans reviewed showed that the home uses a scoring system as part of their assessment and care planning system. For example for physical health a score of 2 means “has a diagnosed condition that does not affect them or is prone to occasional conditions that require monitoring”. The care records were clear in identifying what the scoring meant such as what the “diagnosed condition” may be, this allows staff make sure needs are addressed. It also gives the manager information about the overall needs of people on each unit and address the staffing to meet the extra demand. Care plans were person centred and included a short past history which gives staff an insight into persons past experiences allowing them to see the person as a whole not just as they are today. This promotes respect and understanding. Care plans cover people’s psychological well being and socialisation, this is evidence that the home sees the care holistically and not only physical needs. Risk assessments are also in place for identified risks with the action staff should take to reduce these. Each floor has a medications trolley and a member of staff is allocated to administer medication on each floor. Controlled drugs are stored separately and the administration of these is recorded in a controlled drugs register. Generally medication administration records (MARs) are being signed by staff to confirm medications prescribed are being given. There were no gaps in the signing of medications seen at this visit. People said that their privacy and dignity is respected and confirmed that staff usually knocked the door before entering. Staff were observed to be working singularly only having two staff were needed. This protects people’s privacy and dignity. Meal times were not rushed and people receive assistance as needed and staff did not hover around people waiting for them to finish. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 13 However, one person was seen not eating their meal in their bedroom there was no evidence that staff were aware of this and did not check to see if she was eating. This is not good practice and was reported to the manager. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 14 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 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have access to social activities but these have been further expanded to Make sure that people’s social care needs are met. People generally enjoy the meals provided and are given choices in regard to how care is delivered to help maintain their independence and wellbeing. EVIDENCE: Care plans record personal history information that provides a helpful personal profile about people’s lives and interests. An activity schedule is devised each month and this shows activities such as church service, film night, singing, games afternoon, mobility plus, hairdresser, local shops and bingo. Each person has an activity plan and they are involved in choosing activities. There is a volunteer group that visit the home and assist with activities and one to ones with people. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 15 A Day Care Supervisor is employed who provides activities for the day care visitors and the manager advised that some of the people from the home do join in. People’s relatives are encouraged to visit throughout the day or evening and there are no unnecessary restrictions imposed on their visits. It was evident from the review of care plans that the choices and views of people had been taken into consideration when planning their care. This included whether they would like a bath or shower, whether they had a specific hot drink before they went to bed and details of specific routines they were used to. Breakfast consist of a choice of cereals and also had toast and tea. People said that hot breakfasts are provided if requested and people are asked the day before so the cook knows in advance how many need to be prepared. The main meal consists of two hot choices each day. The cook prepares liquidised meals for those that need them and each item is liquidised separately on the plate to help this look more appetising and appealing. People said the food was good and they generally enjoyed it. On observing the lunch staff were seen to assist people but instead of sitting with people staff were seen to be eating and clearing plates at the same time. This does not give mealtime a feel of socialising, if staff are to eat meals this should either be done after people have finished or used as interaction time with people. . The cook said a four weekly menu is in place and all service users had been provided with a copy of this. She said this is changed seasonally as required. Staff complete resident choices each day to provide to the cook and if people do not like the two choices on the menu each floor has their own alternative menu. The cook advised this includes jacket potatoes, pasties, egg and chips. Fridges and freezers in the home were well stocked with food and the cook confirmed she could have daily meat deliveries if she wishes. Each of the kitchenettes had milk and supplies of bread, margarine, jam etc so that snacks and drinks could be provided for residents as required. During the inspection relatives were observed to also use the kitchenette areas to make a drink. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 16 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 and 18 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Concerns or allegations are taken seriously and are investigated to make sure the protection of people in the home. EVIDENCE: A complaints procedure is in place and is displayed on the wall in the corridor for the benefit service users and visitors and this gives details of who to direct complaints to. Comments, suggestions and complaints books continue to be situated in the hallways on each floor so that service users and visitors can note any comments or concerns and these can be brought to the attention of the manager. It was noted that these books had been well used demonstrating that both people living at the home and visitors feel at ease making any concerns known to staff as well as compliments. Items listed included comments about the food and cleanliness of the home. A complaints log is also in place for recording and tracking formal complaints made about the home. It was evident that any complaints or concerns made WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 17 had been followed up and the findings of investigations recorded. There have been no complaints made to us since the last inspection. The home have policies and procedures in place to deal with allegations made and it was evident that the manager had taken appropriate actions to investigate this matter and take actions to prevent this matter from reoccurring. This has included the provision of lockable facilities in rooms. Appropriate parties had been informed including families. Training information available in the home shows that Abuse training is being provided on an ongoing basis and staff spoken to were aware of types of abuse and what they should do in regard to reporting this. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 18 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 and 26 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well maintained but there is some attention to décor required as well as the cleanliness of the home to make sure that people are cared for in a safe and comfortable environment. EVIDENCE: The home is generally well maintained and has a combined lounge/dining area on each floor and a kitchenette. Residents all stated they were happy with their rooms and those rooms viewed had been personalised with pictures, ornaments etc to make them more homely and giving them a feel of individuality and ownership. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 19 Dining areas were made to look attractive with tablecloths, mats and napkins and a service user on one floor commented on how nice the dining area looked. The home been designed for people with poor mobility, there is a passenger lift, grab rails and assisted baths. Other equipment includes lifting aids ands hoists. The home has a sluice room on each floor to clean and empty commode and undertake any sluicing procedures which is good practice. However, the sluice on the ground floor did not a have a lock and there was a bottle of cleaning fluid. All substances hazardous to health should be stored safely. On touring the building it was noted that a number of commodes in bedrooms were stained and required cleaning. One assisted shower had not been cleaned after use and the shower head was trailing on the floor, this was not good infection control. The fire escape to all three floor required cleaning and the boiler area required clearing of leaves as this was a fire risk. There were no paper towels for staff to dry their hands although liquid soap was available. The Housekeeper said that laundry staff wear tabards and gloves are provided to maintain good infection control practices. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 20 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 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are sufficiently trained staff on duty each day that are available to meet the needs of the people living at the home and systems are in place to make sure staff are not recruited until all checks have been completed to safeguard people. EVIDENCE: There are sufficient numbers of staff on duty each day to meet the needs of people. This is evidenced in the staff rotas. There are dedicated staff to undertake cleaning, catering and the laundry for the home. Both the manager and care manager work in a supernumerary capacity. There is a notice board in the entrance hall of the home that shows who is in charge each day so that any visitors know who to speak to if they have any queries or concerns. Duty rotas show that care staff are allocated to each floor but when staff changes occur these are documented on the “handover attendance record” as opposed the duty rota so both documents have to be used to get an accurate WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 21 picture of the staffing for the home. The manager said that she assess the levels of ability of people on each unit to make sure that the duty rota accurately reflects the movement of people in the home so that it is clear what staff are available and who is supporting each floor. The handover attendance sheet shows that the staffing numbers the home aim to achieve are being met most of the time to ensure there are sufficient numbers of staff to meet the needs of people. Staff continue to undertake National Vocational training level two in care, while a number of others are undertaking or have attained level three. Detailed induction training is available for new staff which is carried out over several weeks to allow them to build up competencies in areas of care and services as appropriate. Statutory training is organised on an ongoing basis and records on display in the Care Managers office show training completed by staff. The manager produced a training matrix that showed statutory training was up-to-date. Other training included a four day dementia awareness course, Protection of Vulnerable adults, Safe Administration of medication, Death Dying and Bereavement and Prevention of Falls. The manager confirmed there were sufficient numbers of staff trained in first aid to ensure a first aider could be on duty at all times. A review of staff files was undertaken to confirm recruitment practices carried out. All of the required information had been obtained prior to recruiting staff to ensure staff had been deemed safe to work with the residents. This included written references, criminal record bureau checks (CRB), protection of vulnerable adult (POVA) checks and suitable identification. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 22 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, 37 and 38 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A person of good character manages the home and quality monitoring systems are in place to make sure the home is run in the best interests of the people who live in the home The health and safety processes and policies protects people and staff. EVIDENCE: Since the last inspection the manager has achieved the Registered Managers Award. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 23 To ensure the home is run in the best interest of the people who live at the home there has been several quality monitoring systems implemented. This includes meetings with people that are attended by the manager as well as a person from Advocacy Alliance who takes the notes of the meeting and raises any issues with the manager on the behalf of people. Since the last inspection a relative volunteer group has been commenced. Actions carried out from the previous meeting had been recorded on the notes so that people knew their suggestions had been listened to and acted upon as appropriate. In addition to service user meetings, each month as part of the care plan reviews, service users are asked a question about how they feel about their care or services provided. Their response is recorded on their file and the manager monitors all responses so that any actions necessary can be carried out. Quality assurance systems in regard to housekeeping and catering are in the process of being started. The manager said that a formal meeting is held with relatives on an annual basis which includes a question and answer session. Notes of this meeting are kept but were not available during this inspection. The manager agreed to forward these to the inspector for review. Two comment cards from health and social care professionals confirmed that they were satisfied with the overall care and service being provided. The manager advised that the Registered Provider is visiting the home on a monthly basis. A copy of the report of these visits was requested but was not available. It was evident that the Registered Provider is producing reports following visits to the home to comply with Regulation 26 as required. A review of people’s pocket monies was carried out and was being managed safely and accurately. There are comprehensive health and safety records these were inspected and there was evidence that appropriate checks are being carried out to make the home safe for people to live and work at the home. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 24 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 1 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 X 3 X 3 X 3 3 WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement The registered manager must make sure that people living in the home are having their needs met within the categories of registration. Arrangements must be made to make sure all people are assisted to eat where required 2. OP20 23(1)(d) The registered manager must make arrangements to make sure that the leaves in the garden do not collect and present a fire risk The registered manager must make sure that the home is maintained in a clean condition. This includes attention to the fire escape and assisted showers Infection control practices need to be reviewed to make sure that commodes are cleaned regularly. 30/06/08 Timescale for action 30/06/08 3. OP26 23(1) 30/06/08 WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations Where staff are assisting with meals they should either eat after they have finished or eat with people as part of normal interaction. WCS - Four Ways DS0000004265.V361563.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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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