Care Home: Weatherdale Unit

What the care home does well Weatherdale provides a specialist service for those people who have dementia and their carers. People can access the service on a daily basis or through the respite service for longer periods of time should they choose to do so. The unit is well maintained providing a safe, attractive, homely and clean place to live. All facilities are based on the ground floor and are easily accessible and all bedrooms provide single accommodation. There are sufficient staff on duty to meet the needs of the people who use the service. One person commented: "there`s always someone about, you never have to wait long." The unit had a very relaxed atmosphere and we saw that staff had good, friendly relationships with the people staying there. All people spoken with were positive about the care they receive in the unit. Comments received on the day include: "I like it here", "it`s good," and "they (staff) are all very good." Weatherdale is managed by an experienced and competent person to ensure the service is run in the best interests of people living in the unit. What has improved since the last inspection? Care Plans contain information about the actions staff need to take to meet identified needs. Medicines that require cold storage are kept at recommended temperatures. This means people who use this service can feel confident there medication is being stored appropriately. Some of the people who attend the unit have their medication on a "PRN" basis, this means "as required". The unit has ensured that for these people a care plan clearly details the circumstance in which this medication is to be given, the frequency of the administration and also a method for recording the medicines effectiveness once given. What the care home could do better: The manager has addressed all requirements from the last inspection and there are no requirements made from this inspection. There are two good practice recommendations that the manager should consider implementing. An application to register the manager with us should be submitted. This will ensure that residents can be confident that someone who is appropriately qualified and experienced is managing Weatherdale.The system for formally reviewing the quality of service provided should be further developed by seeking the views of other stakeholders, in order to continually improve the service for people who use the unit. CARE HOMES FOR OLDER PEOPLE Weatherdale Unit 31 Weather Oak Harborne Birmingham B17 9DD Lead Inspector Patricia Flanaghan Unannounced Inspection 5th July 2008 08:45 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 Weatherdale Unit DS0000035597.V368280.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. Weatherdale Unit DS0000035597.V368280.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Weatherdale Unit Address 31 Weather Oak Harborne Birmingham B17 9DD 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) 0121 427 1607 0121 678 3745 tina.walstrom@birmingham.gov.uk Not known Birmingham City Council (S) Position Vacant Care Home 10 Category(ies) of Dementia - over 65 years of age (10) registration, with number of places Weatherdale Unit DS0000035597.V368280.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. The unit is registered to accommodate 10 adults over 65 who are in need of care for reasons of dementia and associated challenging behaviours. Registration category will be 10 DE(E) That minimum staffing levels for the residential unit are maintained at 2 care plus a senior member of staff throughout the waking day of 14.5 hours Additionally to the above minimum staffing levels, there must be 1 waking night care a senior on waking or sleeping-in duty for respite care users Levels of staffing must be increased appropriately to reflect the numbers of day care service users Care/shift manager hours and ancillary staff should be provided in addition to care staff 12th July 2007 Date of last inspection Brief Description of the Service: Weatherdale is a ten bedded respite and day care unit that is situated within a purpose built, local authority residential home. The unit is staffed and managed separately from the rest of the home and is registered separately with the Commission. It is funded and run jointly by the Health Service and Social Services and is designed to offer a variety of support services for carers/relatives looking after older people who have dementia and associated challenging behaviours. Support can be in the form of day care, overnight stays, weekend breaks or short stays. Weatherdale is located in a quiet, residential cul-de-sac off a main road in Harborne. The unit is within easy access of public transport routes as well as all local facilities including shops, churches, library and swimming baths. It is a single storey unit with its own entrance with a coded lock. The unit comprises of lounge/dining area with a small kitchenette, quiet lounge, office space, laundry, fully equipped bathroom, two toilets and 10 single bedrooms. Information about the fees charged by the unit was not available on the day of the inspection visit, but is available on request to the unit manager. Weatherdale Unit DS0000035597.V368280.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 that people who use this service experience good quality outcomes The focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. We visited the home on Saturday, 5th June 2008 between 8:45am and 2:30pm. There were seven people staying at Weatherdale at the time of the inspection visit. We used a range of methods to gather evidence about how well the service meets the needs of people who use it. This included talking to people who use the service and observing their interaction with staff where appropriate. We also spoke with manager and staff on duty, looked at the environment and facilities provided and checked records such as care plans, risk assessments, staffing rotas and staff files. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was sent to the home for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for providers to share with us areas where they believe they are doing well. Questionnaires were distributed to relatives and staff during the inspection visit. We received four completed surveys from staff and two from relatives. Their comments about the service provided are included within this report. Two people using the service were identified for case tracking. This is a way of inspecting that helps us to look at services from the point of view some of the people who use them. We track peoples care to see whether the service meets their individual needs. Our assessment of the quality of the service is based on all this information, plus our own observations during our visit. At the end of the visit we discussed our preliminary findings with the manager. We would like to thank the people using the service and staff for their hospitality throughout this inspection. Weatherdale Unit DS0000035597.V368280.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The manager has addressed all requirements from the last inspection and there are no requirements made from this inspection. There are two good practice recommendations that the manager should consider implementing. An application to register the manager with us should be submitted. This will ensure that residents can be confident that someone who is appropriately qualified and experienced is managing Weatherdale. Weatherdale Unit DS0000035597.V368280.R01.S.doc Version 5.2 Page 7 The system for formally reviewing the quality of service provided should be further developed by seeking the views of other stakeholders, in order to continually improve the service for people who use the unit. 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. Weatherdale Unit DS0000035597.V368280.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 Weatherdale Unit DS0000035597.V368280.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 Quality in this outcome area is good. People who are considering using this service benefit from having their care needs assessed so that they can be sure the unit can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Weatherdale provides care to people with dementia on a respite, overnight or day care basis in order to provide support to relatives or carers. Referrals to the unit are usually taken from health or social care professionals and the unit is able to meet a variety of needs. The case files of two people currently using the service were examined to assess the pre-admission assessment process. All of the assessment documentation has been updated since the last inspection. Service users and their families are involved throughout this process and are encouraged to complete a “personal information” assessment. This assessment forms part of Weatherdale Unit DS0000035597.V368280.R01.S.doc Version 5.2 Page 10 a life history for the person and also details individual likes and dislikes about how they want their care given. Each of the files examined contained information gathered during a preadmission assessment that identified all of the person’s needs. Files also contained pre-admission information provided by professional health and social care agencies and incorporated into care plans. The unit also offers families an assessment of their own to ensue that they are getting all of the help and assistance they require in order to look after the person with dementia. Weatherdale Unit DS0000035597.V368280.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 Quality in this outcome area is good. People using this service can be confident that their health needs will be met and they will be treated with respect and dignity at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of our case tracking process we looked at the care records of two people who use the service. Care plans are based on the assessment that is completed before the person uses the service. Each person had care plans that reflected their individual needs. Care plans were available for the identified needs of each person and supplied staff with the information needed to make sure the person’s needs were met safely and appropriately. The unit routinely completes risk assessments for all the residents. People are assessed for their risk of falls, moving and handling, pressure sore Weatherdale Unit DS0000035597.V368280.R01.S.doc Version 5.2 Page 12 development and malnutrition. The risk assessments are kept under review the same as care plans. We saw that a community Dietitian had visited the unit on 30 June 2008 to undertaken a nutritional audit and provide advice to the staff. The unit are using the Nutritional Screening Tool provided by Birmingham and Solihull Mental Health NHS Trust. There were records of weight monitoring in the case files of the two people examined. The psychological needs of people are considered. For example, a risk assessment for one person with an identified potential for demonstrating challenging behaviour recorded that the person might communicate by ‘nonverbal means’. The care plan documented signs that staff should be aware of and information about how to deal with challenging behaviour. People keep their own GP’s when they attend the unit. We were told that if a person using the service for respite care is out of the catchment area for their own GP, they will be temporarily registered with the local GP during this time. All nursing care remains the responsibility of the district nursing service. The nurses who are employed on the unit are there for clinical support only and do not offer nursing care. The systems for the management of medicines in the unit were examined. Medicines are administered by the nursing staff, or senior care staff that have undertaken training in the safe administration of medicines. Medication is safely stored in a locked trolley, which is kept in a locked room. A medicines fridge is available and daily recordings of the fridge temperatures were within recommended limits. There are good systems in place for the receipt of medicines. People are asked to provide their medication upon their admission to the unit, this information is then copied onto a medication administration record sheet (MAR) ready for administration. Any medication remaining at the end of their stay is returned with them when they leave. Records are kept of medication entering and leaving the unit The facility for storing controlled drugs complies with legislation. The controlled drug register is accurately maintained. An audit of the contents of the controlled drug cabinet was made and found to be correct. Medicine administration records (MAR) for the people identified for ‘case tracking’ were examined and had been completed correctly. An audit of the medicines of people involved in case tracking were correct indicating that medicines had been administered as prescribed. We spent a lot of the time in the communal areas with people and staff. People were cared for in a respectful manner and this ensured that their Weatherdale Unit DS0000035597.V368280.R01.S.doc Version 5.2 Page 13 dignity and self-esteem were maintained. Conversations between staff and people using the service were respectful and observations of staff practices found that staff responded promptly and sensitively to the needs of people. Terms of preferred address were on the person’s care plan and heard to be used by staff. All people spoken with were positive about the care they receive in the unit. Comments received on the day include: “I like it here”, “it’s good,” and “they (staff) are all very good.” A person commented in a survey returned to us: “…very happy, always helpful, always there when you need them.” Weatherdale Unit DS0000035597.V368280.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, 15 Quality in this outcome area is good. People using this service are encouraged to take part in activities and to maintain family contacts. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person using the service is asked how they like to spend their day and about the hobbies and interests they each have. The unit does not have a planned programme of activities but staff support people to participate in activities and plan how to spend their time on a day to day basis, depending on their preferences for that day. Staff told us that resources for a number of activities were always readily available in the hobbies storeroom. The staff will consider all of the people who are due to attend that week and look at their personal assessments. The information about individual hobbies and interests is then used to plan for the week ahead. This creates a more person centred approach to activity planning. During the inspection visit we saw staff helping people to make name plates for their bedrooms. We also saw people pursuing individual interests such as Weatherdale Unit DS0000035597.V368280.R01.S.doc Version 5.2 Page 15 knitting and reading. People chatted with each other and staff throughout the inspection. Meals are provided at extra charge for those service users who attend on a daily basis. The cost of meals for those who are using the week’s respite facility are included. Meals are supplied from the kitchen in the adjoining residential home. We were invited to join the residents for lunch. A choice of chicken casserole or lamb stew was available. The meal was hot and tasty and the majority of residents finished their lunch. People were asked if they wanted second helpings, which is good practice. Staff also sat and had lunch with the residents. This helps people relax and enjoy the company of staff whilst eating their meals. This arrangement also gives the staff the opportunity to observe service users and identify any issues they may be having during meal times, such as the need for adapted cutlery, larger plates or a change in their dietary preference. We saw people being helped to eat their meals and staff did this in a sensitive and caring way. The unit is also able to cater for specialised diets where needed. Three people spoken with told us they enjoyed their meal. They said; “The food is usually very good,” ““I like dinners;” and “yes, it was very nice.” Weatherdale Unit DS0000035597.V368280.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 Quality in this outcome area is good. People living in the unit can be confident that their concerns will be listened to and acted upon. There are systems in place to respond to suspicion or allegations of abuse to make sure people who use the service are protected from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Weatherdale has a complaints procedure, which is accessible to people using the service and their relatives. The unit have not received any complaints, but have received a number of compliments. We have not received any complaints about this service since the last inspection. A record of complaints and concerns received by the unit is kept along with the action taken by the manager regarding each issue raised. Evidence was available that the manager makes a timely and objective response to concerns raised. People spoken with said they knew how to complain. People were observed to be familiar with the staff on duty and felt confident to make requests. This suggests people would be confident in raising concerns with staff. One person Weatherdale Unit DS0000035597.V368280.R01.S.doc Version 5.2 Page 17 said, “I would tell one of the staff, but what’s there to complain about? We’re all right here” There is a copy of the local authority guidance for the Protection of Vulnerable Adults on the unit. Staff have had training in recognising signs and symptoms of abuse since the last key inspection. It was evident through discussions with staff that they are aware of local Social Services and Police procedures and their responsibilities for responding to allegations of abuse. This should ensure that people using the service are protected from harm or abuse. Weatherdale Unit DS0000035597.V368280.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, 24 and 26 Quality in this outcome area is good. The unit is well maintained providing a safe, attractive, homely and clean place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Weatherdale is a single storey ten-bedded unit, which is attached to a large residential unit. The unit was clean, warm and generally well maintained. Parking is available in the main home and there is a small garden area for residents with potted plants and seating for when the weather permits. There is one combined lounge dining room and a small quite room, which were pleasantly decorated and furnished. There are ten single bedrooms with wash hand basin, call bells and locks to doors. All rooms are adequately furnished. There are special, soft foam Weatherdale Unit DS0000035597.V368280.R01.S.doc Version 5.2 Page 19 mattresses for beds, reducing the risk of pressure sore development to people. All rooms have a lockable facility for people to store valuables should they wish to do so. There is a small kitchen facility on the unit where staff can make drinks and snacks when needed. The laundry and the sluice facility have keypad locks, this reduces the risk of people entering these rooms where they may be placed at risk. The laundry is small but is sufficient to meet service users needs, staff have access to gloves, aprons and liquid soap is freely available for hand washing. The sluice has been fitted with a macerator and a pot washer to ensure that commode pots are cleansed effectively. Since the last inspection, staff have completed infection control training. All of this will help staff to reduce the risk of cross infection to people who use the service. Weatherdale Unit DS0000035597.V368280.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 Quality in this outcome area is good. People using this service can feel confident that there are sufficient staff on duty to meet their needs and that they have been recruited in a manner that safeguards their interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The unit is staffed by both Birmingham City Council and the Birmingham and Solihull Mental Health NHS Trust. The qualified nurses are on the unit to provide clinical support to the care workers and are not responsible for the overall care of service users during this time. On the day of the inspection visit there was a nurse and two carers on duty for the seven people using the service. Six of these people would be remaining overnight when there would be two care staff on duty. During conversation, one person told us, “there’s always someone about, you never have to wait long.” The personnel file of a recently recruited staff member was examined. This person had transferred from another home owned by the local authority. The file contained evidence that satisfactory pre-employment checks such as Criminal Record Bureau (CRB), Protection of Vulnerable Adult (PoVA) and Weatherdale Unit DS0000035597.V368280.R01.S.doc Version 5.2 Page 21 satisfactory references were obtained before staff started working in the unit. Robust recruitment practices safeguard people living in the unit from the risk of abuse. A training matrix is maintained and used to record staff training and to identify any gaps in learning. Records demonstrate that all staff complete an induction programme and receive mandatory training in moving and handling, infection control, abuse awareness, fire safety and food hygiene. This should mean that staff are updated in safe working practice. Weatherdale Unit DS0000035597.V368280.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 and 38 Quality in this outcome area is good. The unit is managed by an experienced and competent person to ensure the service is run in the best interests of people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been in post for six months and is experienced in the care of older people. She is suitably qualified to run the unit. She has a National Vocational Qualification (NVQ) at Level 4 in care and the Registered Managers Award (RMA). She also has an NVQ Level 5 in Business Administration. At the time of writing the report, we had not received an application from the local authority for the person employed as manager to be registered. Action should Weatherdale Unit DS0000035597.V368280.R01.S.doc Version 5.2 Page 23 be taken to ensure an application is submitted so that we can be sure an experienced and qualified person is managing the care home The manager completes monthly audits of care plans, medication and health and safety checks. In addition to this they regularly seek the views of service users and their carers. The last survey was undertaken in June 2008 and not all had been returned to the unit at the time of this inspection visit. We were told that the results will be collated and analysed and action plans developed to address issues raised. The manager told us in the Annual Quality Assurance Assessment (AQAA) that she plans to produce a quarterly newsletter to inform people of information and change. She also intends to re-introduce carers group meetings. It is recommended that feedback should also be sought from other stakeholders such as health professionals, social workers, staff and other visitors to the unit to improve the system. There is a lockable facility in each bedroom should service users wish to lock their money and valuables away safely. The unit does not normally handle any money on behalf of people using the service. If the facility is required any valuables brought in would be securely stored with receipts available. At the time of the inspection visit nobody was using this facility. Information provided by the manager on the AQAA shows that the unit has undertaken the required safety checks related to electrical and gas installations, portable appliances, hoists and other equipment. A random check was carried out on maintenance, servicing and health and safety checks, which included in-house fire safety checks. These were in good order and staff had undertaken mandatory health and safety related training, indicating that the unit was a safe place for people to live and work. Weatherdale Unit DS0000035597.V368280.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 X 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 X X X X 3 X 3 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 X 3 Weatherdale Unit DS0000035597.V368280.R01.S.doc Version 5.2 Page 25 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 Refer to Standard OP31 Good Practice Recommendations An application to register the manager with us should be submitted. This will ensure that residents can be confident that someone who is appropriately qualified and experienced is managing the unit. The system for formally reviewing the quality of service provided should be further developed by seeking the views of stakeholders, in order to continually improve the service for people who live there. 2 OP33 Weatherdale Unit DS0000035597.V368280.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Weatherdale Unit DS0000035597.V368280.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. 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