Care Home: Welbourn Manor

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What the care home does well This home is well managed and people living here are able to make choices with regards to their daily life. It is being well maintained and now provides clean and comfortable accommodation for people living here. Comments were generally positive about the care and services provided and staff members were observed carrying out their duties with kindness and sensitivity towards the residents. Many of the staff had worked at the home for several years, providing continuity of care. What has improved since the last inspection? The provider has taken action to address the requirements and recommendations given during the previous visit. Action has been taken to ensure all equipment in need of servicing and repair/replacement has been completed, this included a full refurbishment ofthe lift and repair to the flooring in one of the bathrooms enabling the 2nd bath hoist to be fully operable. A new call bell system has been installed. The fire alarm system is fully operable and was tested during the visit. New furniture has been provided in fourteen bedrooms and additional heating has been provided in two of the bathrooms. Staff are now having regular supervision and an annual appraisal system has been set up. What the care home could do better: The Statement of Purpose and Service User Guide must tell people how they can access our reports and everyone must be made aware of the complaints procedure and our correct contact details. Care plan reviews must show resident and/or representative involvement to ensure people are able to express their views. There should be more opportunity for people to engage in activities within the home to meet individual needs. Staff should have training relevant to the specific needs of people living at the home; training should include learning disability/autism, mental capacity and NVQ. Quality monitoring should be extended to include obtaining the views of all stakeholders involved with the service. CARE HOMES FOR OLDER PEOPLE Welbourn Manor High Street Welbourn Lincoln LN5 0NH Lead Inspector Elisabeth Pinder Unannounced Inspection 8th April 2008 09:00 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 Welbourn Manor DS0000061236.V362008.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. Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Welbourn Manor Address High Street Welbourn Lincoln LN5 0NH 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) 01400 272221 www.guardiancarehomes.co.uk Guardian Care Homes (UK) Limited Mrs Susan Hughes Care Home 31 Category(ies) of Dementia - over 65 years of age (4), Learning registration, with number disability over 65 years of age (1), Mental of places disorder, excluding learning disability or dementia (1), Old age, not falling within any other category (31) Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories: Old age, not falling within any other category (OP) 31. Dementia, over 65 years of age (DE(E) (4) on a named basis only. Mental Disorder, under 65 years (MD) (1) on a named basis only. Learning Disability (LD)(E) (1) on a named basis only. The maximum number of service users to be accommodated is 31. 2. Date of last inspection 10th April 2007 Brief Description of the Service: Welbourn Manor is a large house dating back to medieval times; it was originally a large, country manor house. It stands in mature gardens, one area of which is enclosed, accessible and safe for the residents to use. It is a Grade 1 listed building so any alterations or adaptations to the inside or outside need to be approved by the local council authority. It is situated in the centre of the village of Welbourn, which is between Lincoln and Grantham and has good road and public transport links to both. The home is owned and run by Guardian Care Homes UK Ltd. The care home is registered to provide personal care, not nursing care, for up to thirty-one people of both sexes over 65 years. The home can also provide care for up to four named people with dementia needs and one named person who is under 65 years of age. Bedrooms are located on the ground and first floor; a lift is available for people to access the first floor. Bedrooms do not have en-suite facilities. There are four communal bathrooms and eight toilets. On the day of the site visit twenty people were living in this home, two of whom were in hospital. Parking is available at the front of the building. Fees range between £348 and £435 per week. Additional charges are made for services such as chiropody, hairdressing, newspapers and personal toiletries. Welbourn Manor DS0000061236.V362008.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. This unannounced visit to the home was undertaken by one inspector and formed part of a key inspection, focusing on all the key standards. Throughout this report the terms ‘we’ and ‘us’ refer to The Commission for Social Care Inspection (CSCI). The visit started at 9.00 a.m. and lasted 5¾ hours. Prior to the visit the manager had returned their Annual Quality Assurance Assessment (AQAA), this gave important information about the service, which was used in the planning of the inspection and will be mentioned throughout this report. Information was also gathered from the previous inspection report, events that we had been told about and the home’s service history. Surveys had been received from people using the service, their relatives/advocates and staff working in the home. The visit included following the care of five people with a range of needs through checking records that are held about them, talking with them and with two staff members on duty. Other residents were spoken with in general conversation, as was one relative. Short periods of observation were spent at various times of the day of staff carrying out their duties. A partial tour of the home and a review of a sample of the records were also included. What the service does well: What has improved since the last inspection? The provider has taken action to address the requirements and recommendations given during the previous visit. Action has been taken to ensure all equipment in need of servicing and repair/replacement has been completed, this included a full refurbishment of Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 6 the lift and repair to the flooring in one of the bathrooms enabling the 2nd bath hoist to be fully operable. A new call bell system has been installed. The fire alarm system is fully operable and was tested during the visit. New furniture has been provided in fourteen bedrooms and additional heating has been provided in two of the bathrooms. Staff are now having regular supervision and an annual appraisal system has been set up. 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. Welbourn Manor DS0000061236.V362008.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 Welbourn Manor DS0000061236.V362008.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): 1, 2, 3, 4 & 5 Standard 6 is not applicable Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home is available and there are good systems in place to introduce and assess people, to ensure their care needs are identified and can be met prior to admission. EVIDENCE: The home’s Statement of Purpose and Service User Guide were available for inspection and both gave detailed information about the services and facilities offered. Although it is acknowledged that a copy of our report was available in the entrance area of the home neither documents told people how they could access our reports and the manager agreed to include this information. Surveys received gave a mixed response regarding information people had been given to help them decide if it was the right place for them, two felt information was sufficient and two did not. Two people spoken with during the Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 9 visit confirmed that they had been given sufficient information about the service and said they were very satisfied with the care being given. However, one comment written in a survey read; ‘the information I receive is only when there will be a rate increase in fees. I would like to know what the home plans for every day living as when I visit it seems the residents are bored and just sitting around’. This was discussed with the manager who said this has been raised with her and addressed and a bi-monthly newsletter is being developed. The pre-admission assessments of two people recently admitted to the service were examined, these had been well written and included detailed information about their needs, including, personal hygiene, communication, mobility, nutrition, spiritual and cultural and social interests. From this information care plans had been commenced indicating the help and support residents needed. Confirmation sent out to people after their assessment to confirm that the home could/could not meet their needs were available on individual files together with terms and conditions of residency. Welbourn Manor DS0000061236.V362008.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. Care plans identify the needs of people and the action staff need to take to meet these. However, they are not person centred and there is a lack of resident/representative involvement therefore people may not be able to express their views. There are satisfactory policies and procedures in place about the administration of medication and the privacy and dignity of residents is respected. EVIDENCE: The company use the same format for all care plans where the name of the person is entered onto a pre-populated form. However, these are supported by comprehensive admission assessment forms. Care records examined gave information on how the needs of people should be met. Identified needs included religious wishes, social stimulation, physical and mental health needs. Records also detail end of life wishes, when these had been made known. Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 11 Although staff review care plans monthly, there was no evidence that residents or their representatives had been involved in these reviews. One relative spoken to said he was unaware of his mother’s care plan but said she had not been living at the home very long. The manager agreed to ensure this would be addressed. This had also been highlighted during the previous inspection. Risk assessments had been completed for activities of daily living, such as, bathing, dressing, feeding and falls. Referrals to health care specialists were made when necessary and people are able to see health professionals in the privacy of their rooms. Three surveys received from people living at the home indicated they ‘usually’ receive the care and support needed, one indicated ‘sometimes’. No specific comments were made. 100 of the relative/advocate surveys received indicated the service ‘always’ meets the needs of their relative/friend and all but one said they are kept up to date with important issues. Some of the comments read: ‘The fact that my mother has put on weight since arriving at Welbourn Manor and always seems very contented there leads me to believe that her care is much greater than she previously had at home;’ and ‘Always contact me when a problem arises, when you arrive at home on visits, staff are always helpful and friendly’. The staff member giving people their medication did so using safe procedures and confirmed she had undertaken relevant training. The manager said that staff are currently completing a twelve-week distance-learning course to update their medication training. Records checked were well maintained and drugs were stored correctly. The home does not have a visiting pharmacist and monthly audits are done by the manager. None of the people whose records were looked at in detail looked after or took their medicines themselves. General care practices were observed throughout the visit, staff spoke to people using their preferred name as recorded on their care plans and were polite and courteous. Staff spoken with had a good knowledge of the care needs of people they were asked about. Welbourn Manor DS0000061236.V362008.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 adequate. This judgement has been made using available evidence including a visit to this service. People living in this home have a balanced diet based on their likes, dislikes and choices. Although they have access to some activities, they would benefit from the opportunity to engage in more activity within the home. EVIDENCE: Surveys gave a mixed response regarding the provision of activities, two people indicated that activities are ‘always’ available that they could take part in and two indicated ‘sometimes’. Since the last inspection the activities coordinator has increased her hours and now has twenty hours dedicated to activities each week. Although she was on annual leave during the inspection the manager said she is currently writing individual activity plans for residents and is meeting with families to gather more information about hobbies and interests. Surveys received from relatives/advocates indicated they would like to see more activities and outings. Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 13 Information provided in the AQAA told us that the home has improved links with the community and about the managers plan to implement a bi-monthly newsletter detailing forthcoming activities/events. During the visit some people were seen doing a puzzle and listening to music, others were reading their newspaper or watching television. Records of past activities were not available but people told us they had recently made cards and cookies and were planning a summer fayre. Information provided in the AQAA also read that people ‘are given choices regarding clothes, bathing and food and special diets are catered for’. People spoken with during the visit said they are able to choose how to spend their day, what they wear and to some extent what they eat. Most people said they liked the meals. A four-week menu is used and there is a choice of food at each meal. During the visit the main meal was chicken pie or lasagne, fresh vegetables and potatoes. Tables were nicely laid with tablecloths and flowers and people said they enjoyed their meal. Visitors were seen to come and go throughout the visit and residents said they could receive visitors whenever they wish and a relative said that staff always welcome them into the home. Welbourn Manor DS0000061236.V362008.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. People living in this home are confident that any concerns would be addressed appropriately. Robust procedures are in place for reporting allegations of adult abuse. EVIDENCE: The home has a complaints procedure, which tells people how to make a complaint and how it will be handled. However, this does not include the correct contact details for us. The service has received one complaint within the last twelve months, however, records were unavailable for this and the manager said they had been archived. Surveys received from people living in the home all indicated they know how to make a complaint and feel staff listen and act on what they say. A varied response was received from relatives/advocates, four indicated they knew how to make a complaint, one could not remember and another said they did not know. However, all said the home had responded appropriately to any concerns raised. The manager agreed to re-issue the complaints procedure giving up to date contact details for us. Staff spoken with had a good knowledge of the complaints and safeguarding adult’s procedures and their responsibilities for reporting any allegations to the manager or provider. They confirmed they had covered this during their NVQ Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 15 (National Vocational Qualification) training and some staff had completed specific safeguarding training. Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in this home live in a clean, pleasant and hygienic environment and they are able to personalise their rooms. EVIDENCE: Information provided in the AQAA indicated that the home is decorated to a high standard and bedrooms are re-decorated as they become vacant. A dedicated team of domestic staff are employed as well as a handyman/gardener. The bedrooms of people ‘case tracked’ were viewed and all were clean and tidy and well personalised. People spoken with said that they found their rooms to be comfortable and had been able to make them more homely with their own personal belongings. Information taken from surveys indicated that most people feel the home is ‘always’ kept fresh and clean. One comment read, ‘my Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 17 bedroom sometimes needs dusting, apart from that I am happy the home is nice and clean’. Staff were seen wearing protective clothing. Since the previous inspection improvements have been made including a new emergency call system, a major refurbishment to the lift, fourteen bedrooms have had new furniture, repairs have been made to one of the bathrooms enabling a second hoist to be working and additional heating has been installed in two of the bathrooms to make them warmer for the people using them. Areas of the home seen were clean, pleasant and homely with no unpleasant odours. The Environmental Health Officer has not yet visited within the last twelve months. Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. There are satisfactory staffing arrangements in place to meet the current needs of residents. However, there are shortfalls in the training programme that may result in residents’ needs not being fully met. EVIDENCE: Staffing rotas examined showed that there are usually three care staff on duty from 08:00 – 20:00 hrs and two staff throughout the night. Four questionnaires were received from people living at the home and three of these indicated staff are ‘usually’ available when needed, one indicated ‘sometimes’. People spoken to during the visit all said they felt enough staff were on duty to meet their needs. Currently there are no male carers and therefore people are unable to choose who provides their personal care. One person spoken with said he would ‘like to have a male carer to assist him with bathing needs’, but is aware of the difficulty in recruiting male staff. Although many of the staff had worked at the home for several years, which provides continuity of care, records show there has been quite a high turnover of staff within the last twelve months. Three staff have left, others are on long-term sick leave. However, the manager explained that one person has returned from sick leave and she is currently recruiting as two other staff are leaving at the end of this month. Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 19 Staff surveys varied in their response regarding whether there are enough staff to meet individual needs, one identified ‘always’, two ‘usually’ and one ‘sometimes’. Two felt they ‘sometimes’ have the right support, experience and knowledge to meet the different needs of people, one ‘always’ and one ‘usually’. Specific comments read, ‘we are kept up to date with training but would like to see members of staff able to do National Vocational Qualification (NVQ) level 3’ and ‘if there was more team work it would be a lot easier for everyone’. The majority of relative/advocate surveys indicated staff ‘usually’ have the right skills to look after people properly. One comment read, ‘motivation is lacking, but all in all my mother is well looked after”, another read, ‘I am staggered at the kindness and dedication of the staff’. One negative comment received regarding an incident was made and this was brought to the attention of the manager who agreed to address the issue immediately. Training records showed that staff had participated in a range of training such as medication training, health & safety, safeguarding adults and fire training. However, the current registration of the service includes one person with a learning disability and staff have not had any training relating to this and had very limited knowledge of the Mental Capacity Act. The AQAA identified that 25 of staff have obtained a nationally recognised vocational award in care, which is below the recommended 50 . The records of one new member of staff employed since the previous inspection were examined and these showed that they had been recruited using safe, robust procedures and had completed induction training. All care staff have been given copies of The General Social Care Council Codes of Practice, which enable them to understand their responsibilities as care workers looking after vulnerable adults. Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements are satisfactory. There are some systems in place to obtain views in order to monitor the quality of the service and procedures are in place to promote the health and safety of people living at the home. EVIDENCE: The manager was registered in December 2006 and is currently undertaking the Registered Managers Award. Positive comments were received from people living at the home, their relatives and staff about the support the manager gives. Since the previous inspection staff have received regular supervision and an annual appraisal system has been set up. Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 21 Information given in the AQAA read that policies were updated in 2006 and staff on duty knew where to find them and confirmed that they were always accessible. The AQAA also showed dates when equipment was serviced and fire alarms checked. The manager sent out quality monitoring questionnaires to relatives in December and to date only eight have been returned. Information taken from these will be collated, and if necessary, a plan of action will be drawn up to address any issues and further improve the service. A discussion was held regarding extending questionnaires to other stakeholders, for example General Practitioners (GP’s), district nursing services and social workers and the manager agreed to look into this. Generally records required by law to be kept about the operation of the service were up-to-date and well maintained. There are a range of policies and procedures in place, which help to ensure the health and safety of people living at the home is regularly assessed. Monthly visits to the home from the provider are made. The last report available was dated 14th February 2008. Information provided to us in the AQAA confirmed that regular maintenance checks are carried out on the environment and the equipment in use. During the visit electricians were in the home carrying out a check on the electrical wiring. The finances of people ‘case tracked’ were checked and found to be in order with good written records. Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Reviews of care plans must be improved to show that residents and/or their representatives have the opportunity to be involved. Appropriate activities and leisure opportunities for residents to participate in must be provided to meet individual needs. All staff must be adequately trained to carry out their roles. Training should include specialist training regarding learning disability/autism and mental capacity. Timescale for action 31/05/08 2. OP12 16[2][n] 31/05/08 3. OP30 18[1][c] [i] 30/06/08 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. Refer to Standard OP1 OP28 Good Practice Recommendations The statement of purpose and service user guide should detail how people can access copies of our reports A minimum of 50 of care staff should be trained to NVQ DS0000061236.V362008.R01.S.doc Version 5.2 Page 24 Welbourn Manor 3. OP33 level 2 Quality monitoring should be extended to include obtaining the views of all stakeholders involved with the service. Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Welbourn Manor DS0000061236.V362008.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!