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Inspection on 02/09/08 for St Wilfrid`s Care Home

Also see our care home review for St Wilfrid`s Care Home for more information

This is the latest available inspection report for this service, carried out on 2nd September 2008.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

St Wilfrid`s is a well managed home that provides a high standard of care for the people who live there. The feedback from residents and their families was very positive and highlighted their involvement in their care and the running of the home. St Wilfrid`s has an ethos, which is focused on meeting the diverse spiritual, cultural, social, and health needs of the individual residents. There is a focus on staff development for staff at all levels which has created a good staff team committed to provide good person centred care. St Wilfrid`s provide a comfortable clean and well maintained environment. They have excellent health and safety policies, procedures and record keeping. St wilfrid`s has enthusiastic managers who provide a clear direction for the home informed by an understanding of people`s needs.

What has improved since the last inspection?

St Wilfrid`s have met all the requirements set at the last inspection. They have developed person centred care plans which they are in the process of writing with the residents. They have also developed a social plan for each person which includes cultural and religious needs. They have developed the training for all staff and produced excellent training material and handbooks for the staff.

What the care home could do better:

Make sure that all senior staff have training in staff supervision. It is also recommended that references are sought for all volunteers and that they have training in health and safety, the details of which to be recorded.

CARE HOMES FOR OLDER PEOPLE St Wilfrid`s Care Home 29 Tite Street London SW3 4JX Lead Inspector Ann Gavin Key Unannounced Inspection 2nd September 2008 11:00 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 St Wilfrid`s Care Home DS0000010850.V371630.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. St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Wilfrid`s Care Home Address 29 Tite Street London SW3 4JX 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) 020 7351 5339 020 7376 5539 pauline.dodd@stwilfridssw3.org.uk The Congregation of the Daughters of the Cross of Liege Pauline Margaret Dodd Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 44 6th September 2007 Date of last inspection Brief Description of the Service: St. Wilfrid’s Convent is a large purpose built residential home for up to 44 older people located in an attractive area of Chelsea. The proprietors are The Congregation of the Daughters of the Cross of Liege. Sisters of the order live in an attached annex. The home comprises of five floors, the lower ground floor provides a lounge/conservatory and a dining area, the main kitchen and laundry. The ground floor main entrance leads to the reception area, this floor comprises of a communal lounge, the managers office, several meetings rooms and administration areas. The upper floors provide single bedroom accommodation, and all are provided with ensuite facilities. Small lounges are located on each floor, as are specialist bathing and toilet facilities. Three passenger lifts and two internal staircases provide access to the upper floor of the home. To the front are well landscaped and maintained gardens. The fees range from £635 to £875 per week St Wilfrid`s Care Home DS0000010850.V371630.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 3 star. This means the people who use this service experience excellent quality outcomes. This was an unannounced inspection on Tuesday 2nd September from 11.30 am to 8 pm. This report is made up of information gained from speaking with residents, staff, and managers as well as looking at records, tracking the care of four residents and a tour of the communal areas of the home. The information provided by the manager in the Annual Quality Assurance Assessment (AQAA) was also used. There were 13 residents, 10 relatives/visitors, 16 staff, and 3 professional questionnaires returned. Their comments have been included in the report. What the service does well: What has improved since the last inspection? St Wilfrid’s have met all the requirements set at the last inspection. They have developed person centred care plans which they are in the process of writing with the residents. They have also developed a social plan for each person which includes cultural and religious needs. They have developed the training for all staff and produced excellent training material and handbooks for the staff. St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 6 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. St Wilfrid`s Care Home DS0000010850.V371630.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 St Wilfrid`s Care Home DS0000010850.V371630.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 (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. St Wilfrid’s has good procedures for assessing people’s needs before they move into the home. Everyone has the opportunity to visit the home proper to admission. All residents now have new contracts. EVIDENCE: ‘All potential service users now have access to new terms and conditions of residence, comprehensive Service users Guide. They receive a informative letter, brochure, copies of the most recent menus and activities program and a copy of the yearly accounts. All potential service users have a full needs assessment to establish that we are able to meet their needs prior to admission. This tool is used as the first part of the process in planning their care…’ Extract from Annual Quality Assurance Assessment (AQAA) completed by the manager St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 9 People are encouraged to visit St Wilfrid’s have a meal and met other residents prior to deciding about moving into the home. Every prospective resident has a full assessment of their care needs completed before admission which is carried out by the head of care or the care consultant. St Wilfrid’s has have further developed their pre admission assessment form which now includes peoples social and cultural needs, as well as an assessment of their health and care needs. There is also a section to discuss people’s anxieties about admission. These assessments are more informative and give a clearer picture of the persons care needs and preferences. Once a person has decided to move into the home they are sent a contract prior to admission. Every person in St Wilfrid’s has been issued with their updated and clear contract. Evidence of this was seen in the files of the four people whose care was tracked. The service user’s guide has been updated to give people more information on the ethos and services available within the home. St Wilfrid`s Care Home DS0000010850.V371630.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. St Wilfrid’s have developed new person centred care plans for all the people living in the home. People felt they were supported in a dignified and respectful way. New links have been made with local health professionals to enhance the health care of all residents. EVIDENCE: ‘I just like it here. I’m looked after rather well. I think it’s a good home’ Quotes from resident The Manager and her team have worked hard to create completely new person centred care plans for all residents. Originally they amended the existing care plans but they found it yielded limited benefit therefore they decided to change the whole plan and documentation. St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 11 They have also developed and put in place principles and guidelines for care planning. All staff have been trained in the new care plans and are currently working with the residents to update and create their care plans into the new system. ‘Prior to implementation of the new system a prototype care plans was given to all senior care staff to trial on a mock service user. All the seniors received one to one training with many opportunities for feedback and correcting shortfalls. This process was protracted but essential before implementing the new documentation. ‘ Extract form Annual Quality Assurance Assessment (AQAA) completed by the manager The care of four people was reviewed through discussions with them, with staff and through looking at their care plans. Two of the people chosen had the new care plans. They were very good, person centred giving an overall profile of the person, their preferences and how they wish to be supported. Peoples preferred way of dressing is also included as is their morning routinebreakfast in bed or in the dinning room etc. Each care plan now has a personal history of the person written by them which is kept at the beginning of the plan. The care plans starts with baseline observations on admission covering all the key areas of health- skin integrity, weight etc, as well as areas that need to be looked at to maintain a safe environment. One person had a fall prior to admission and the care plan stated how ‘X had a fall recently and has lost confidence. Aim to regain confidence…’ the care plan went on to outline how this person’s confidence could be regained in various areas. There were clear details of the amount of support required in each area of care. For example ‘Always ensure their walking aid is placed within their reach at all times. Make sure you walk at X pace ‘ People said the care they received was good and that the carers were respectful and treated them with dignity. The care plans also contain more comprehensive risk assessments for each area to ensure that people are kept safe. The new assessment forms contain generic risks that people might be prone to as a prompt and help to aid care staff. These include the possible hazards and ways to prevent them and create a safe environment for each person. The assessments are then personalised to the individual. Care must be taken that the assessments do not just remain generic. The home now have links with the community rehabilitation team and have been working closely with them with regards to people who have had falls. The incidents of people having repeated falls have dropped as a consequence. St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 12 There are clearer records in place to monitor people weight and other health needs. A separate sheet is also in place to record all health related visits and outcomes. The manager explained that they wanted a system that would meet people’s needs but also enable senior staff to carry out audits on care plans. People who live at St Wilfrid’s either retain their own G.P. or join the G.P. practise which visits the home. The local G.P. visits weekly and residents now can either see the doctor in their own room or in the homes surgery. There are close links with the local district nurses and also with a local hospice. The hospice has provided some training in end of life care. The manager says that since the link with the hospice more people have been able to be cared for in the home until their death. One of the residents whose care was tracked uses a hoist. The moving and handling assessment was seen and there was also evidence that staff had been trained in the correct use of the hoist for the safety of the person and the staff. Staff also commented on how much the purchased of height adjustable beds for all residents has made a difference to providing good safe care of people. Some of the residents had found them hard to adjust to. The managers and staff discussed with the residents the purchase of the beds and the need to enable safe care practices. One of the residents spoke of how the beds took getting used to but they have adjusted to them now. Medication and MARs (medication administration records) records were checked. They were well kept and recorded. The pharmacist is carrying out an audit next week. The home now has individual blister packs for residents. Staff says that these work well. All loose medication and bottles are kept in the medication trolley or the medication cabinets. All opened bottles had the date of opening. Only the senior care staff administer medication and all have completed a practical competency assessment. The head of care and the care consultant checks in the medication and they also carry out regular audits. One person in St Wilfrid’s retains their own medication. St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. St Wilfrid’s has sought the views of the residents and considered their varied interests when planning the routines of daily living and arranging activities both in the home and the community. They have developed a social plan for each person which includes cultural and religious needs. EVIDENCE: ‘Each service user has their own social plan including a social profile life, biography, a map of life and a list of social likes and dislikes the social plans are updated with all social activities that each service user attends Extract from the Annual Quality Assurance Assessment (AQAA) completed by the manager ‘Everything is fine, if I don’t want to take part I am not coerced ’ ‘Very good chefs and cooks in fact excellent’ ‘I think sometimes we have too many sandwiches but most days it is reasonable food’ ‘I would like people to have more time to take me for walks..’ St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 14 ‘The activities I take part in are the flower show, one or two musical eventsI will try to go to more…’ ‘The activities coordinator is awfully good’ Quotes from residents St Wilfrid’s have a full time activities coordinator who creates the social and cultural calendar with the residents. A copy of which is then sent to each resident and their family if wanted. The activities coordinator has been developing peoples individual social plans to ensure that their diverse needs are met. Residents create their biography and social history and a list of interests and preferences. The activities coordinator arranges individual sessions for residents. Talking with residents the coordinator is gradually building up peoples map of life which highlights their school family, interests and dreams ‘if you could what would you really want to do…’ There is a monthly activities plan which includes in house activities such as coffee mornings with a review of the papers, poetry reading, board games, movement and music, art and crafts, talks, film matinees. There is a large room for social activities, a library, television room and quiet rooms. Currently one of the lounges has been dedicated as a smoking room though the manager says that will be reviewing this with the residents. St Wilfrid’s have an established group of volunteers who visit every Wednesday and Fridays to assist with either activities in the community or to have individual time with residents. The volunteers also help with theatre trips. The home has established links within the community and often has in house concerts given by local musicians or theatre groups. People are encouraged to maintain control over every area of their lives and the social plan is one example of this. The manager spoke of how residents had decided that a sherry in the conservatory is the preferred choice of venue for a monthly meeting. The more formal six monthly forum was voted out by residents who prefer a more relaxed and informal setting to talk about life in the home and express their views. The activities coordinator takes notes of these meetings. Those seen showed that the new beds were discussed and ideas for social activities. The Saturday following the inspection the home were holding their first garden fete. The residents and their relatives were involved in both the preparations and the events planned for the day. St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 15 A menu committee, made up of a group of residents and sisters, was set up to gather suggestions for the summer menu. Their suggestions formed the main part of the menu which the home is now using. The manager said they would be meeting again soon to prepare an autumn menu. St Wilfrid`s Care Home DS0000010850.V371630.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Wilfrid’s has an open culture that allows residents to express their views and concerns in a safe and understanding environment. They have a clear complaints policy and procedure. EVIDENCE: St Wilfrid’s has a new complaints policy and forms which were seen in the reception of the home. The complaints file showed that all complaints were dealt with and recorded with clear actions and outcomes. There were no outstanding or unresolved complaints. The feedback from residents showed that they all knew who to talk to and what to do if they wished to complain. The complaints file also holds the numerous compliments the staff have received. Talking with the manager confirmed that all the volunteers have had criminal record bureau checks (CRB). The majority have been working in the home for a number of years. It is recommended that references are sought for all volunteers and that they have training in health and safety the details of which to be recorded. All staff had completed training in safeguarding adults and the home has made links with the local safeguarding lead in the local authority and is mindful of keeping up to date with practices and policies. The manager says that all staff have regular training. St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 17 St Wilfrid`s Care Home DS0000010850.V371630.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): 19,20,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Wilfrid’s is clean, safe and comfortable, well maintained and reflects the individuality of the people using the service. EVIDENCE: ‘It’s always clean and fresh ‘ ‘The cleanliness of the home is excellent. My room gets cleaned everyday’ ‘They hover like mad and dust well’ Quotes from residents St Wilfrid’s is a modern attractive home that is clean and fresh. Accommodation is arranged over the first and second floors. Each floor has a small lounge and kitchen. There is also a library, smoking and non-smoking lounge a conference/ activity room and a conservatory. A gardener maintains the attractive gardens. St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 19 St Wilfrid’s also employs a full time maintenance person who is the lead person for all the daily and weekly health and safety checks as well as arranging all maintenance jobs. The domestics now work weekends which ensures an excellent level of cleanliness is maintained. The laundry is also now available at the weekend. One of the domestic staff spoke of how proud they are of their work and the cleanliness of the home. Walking around the communal areas of the home confirmed the high level of cleanliness and freshness throughout the home. St Wilfrid`s Care Home DS0000010850.V371630.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have confidence in the staff who care for them. All staff receive relevant training which is focused on improving the support offered to the residents. EVIDENCE: ‘Staff come to me quite quickly’ ‘The girls are busy. I am not the only one here, I am very grateful’ ‘The staff are all very caring, I don’t know what more they could do’ Quotes from residents ‘The needs of the residents always come first and I believe the staff care a lot which makes the home a happy one for both residents and staff’ ‘Because of better staffing levels we (carers) have more time for individual care’ ‘ The training is really good’ Quotes from staff St Wilfrid’s have had successful recruitment and have increased their permanent staff to the point that they no longer require the use of agency staff St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 21 but can rely on their bank staff. The manager explained that they put adverts in local papers and the job centres and feel that they have recruited quality staff. The staff work in shifts of 8am to 2pm or 2 – 8pm and the night time 8pm to 8 am. Staff are now also on rota for working at nights. This was brought in for continuity of care for residents. The manager and staff said that they feel they understand more peoples needs and also what is expected of the night staff. Staff spoken with also said it has helped to increase the team spirit among staff and a clearer understanding of both day and night time tasks. The increased number of staff during busy periods has remained. ‘We currently have a ratio of 57 of trained care staff with NVQ (National Vocational Qualification) level 2 or equivalent and 13 of our care staff are working towards NVQ level 2’ Extract from the Annual Quality Assurance Assessment (AQAA) completed by the manager The manager explained that they now have two NVQ assessors and the Training Officer is currently completing their training to become an NVQ assessor. The manager and their team have worked to produce excellent training material and handbooks for the staff. Those looked at were for fire training and moving and handling. Both were very informative with a good use of both diagrams and pictures. The managers said they had similar training books covering health and safety, understanding dementia and food hygiene. The staff use these booklets as part of their training which involves a written and practical test. The individual staff keep the handbooks for reference They have training on safeguarding adults from an outside trainer and links with the local social services lead in safeguarding. St Wilfrid’s now have a training tracker which highlights and alerts when each member of staff is due their statutory training. The managers have said they can now see at a glance the training needs of each staff member. The practical induction undertaken by each new staff member over three months has also been reviewed and updated. Staff now need to write comments against each standard in their own individual induction booklet. The head of care and care consultant go through with the staff and test them on each aspect before passing onto the next area. One of the staff spoken with had just started within the last month. They confirmed that they were on an induction programme that they had completed all their statutory training in health and safety, fire, food hygiene and moving and handling. After the initial induction they began in the home by shadowing staff. ‘I was led into everything very gently. What I liked was I had time to get to know the people and the home. I wasn’t just thrown in’ St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 22 A selection of four staff files were looked at. All contained the necessary checks and information as required. The staff interviewed confirmed that training the have received and that they had received supervision. All demonstrated a clear understanding of the needs of the people they supported. St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The ethos of St Wilfrid’s is open and transparent. The views of both people who use the service and staff are listened to, and valued. There are enthusiastic managers who provide a clear direction for the home informed by an understanding of peoples needs and focused on providing good care for the people who live in the home. Health and safety systems are reviewed regularly. EVIDENCE: ‘I think all the people here are wonderful and I am being honest not exaggerating’ ‘ I feel they are trying to make the home as much like my home as possible’ Quotes from residents ‘The home is really good at team work’ St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 24 ‘The home is really well organized’ ‘We are like a big family’ ‘There is a strong management structure in place now and the residents enjoy the monthly meetings’ Quote from staff The manager has been in post since May 2007 and has worked closely with the deputy manager, care consultant, the head of care and senior managers to promote an open and focused culture within the home. They have sought the views of the people who live in the home via informal monthly sherry mornings and also through a quality service analysis carried out in February 2008. This involved sending out 90 questionnaires to residents, relatives and volunteers. The response was 47 questionnaires returned and the feedback was collated. The areas covered included overall satisfaction 60 of people felt the quality of the service was good, 34 excellent and 6 neither good nor bad. The overall staff rating was also positive. The manager has completed a business continuity plan which is now available for anyone at the reception. There is also a quality assurance system in place. All staff now have supervision contracts and receive supervision. The four staff files looked at all had supervision contracts in place. Staff spoken with confirmed that they have been going through the supervision contracts and that they now have a written record of any supervision. The senior staff share supervision of the staff between them. All seniors must be trained in supervision so as to give appropriate support to staff who work with the people who live in the home. There is a good system in place for residents’ monies. Those records seen were well kept and correct. The selection of health and safety records seen they were very well maintained and recorded. St Wilfrid’s have developed excellent fire safety procedures. These are detailed, thorough and specific to the home with clear day and night fire plans and fire zones. They are accompanied by excellent level of training and fire procedures. These include an evacuation plan with an identified place of safety. The local fire brigade have been informed and sent a plan of the home with the fire zones. The fire bag which is kept in the reception is updated regularly. The records of contracts for the upkeep and service of all the health and safety aspects of the home have been updated to a clear auditable standard. St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 25 St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 26 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 3 3 X 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 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 3 3 3 3 4 St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 27 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 OP36 Regulation 18 Timescale for action All senior staff must be trained in 31/12/08 supervision so as to give appropriate support to all staff who work with the people who live in the home. Requirement 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 OP18 Good Practice Recommendations It is recommended that references are sought for all volunteers and that they have training in health and safety, the details of which to be recorded. St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 St Wilfrid`s Care Home DS0000010850.V371630.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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