Inspection on 30/05/07 for Wilbury Rest Home

This is the latest available inspection report for this service, carried out on 30th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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.

Similar services:

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Wilbury Rest Home 66 Wilbury Road Hove East Sussex BN3 3PA Lead Inspector Jennie Williams Key Unannounced Inspection 31st May 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wilbury Rest Home DS0000068865.V337545.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. Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wilbury Rest Home Address 66 Wilbury Road Hove East Sussex BN3 3PA 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) 01273 326170 01273 326170 wilbury@tinyworld.co.uk Dean Care Limited Graham George Dean Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is nineteen (19) That service users must be over sixty-five (65) years or over on admission. New Registration Date of last inspection Brief Description of the Service: Wilbury Rest Home is a care home providing care for nineteen (19) residents over the age of sixty-five (65). Wilbury Rest Home is located in a quiet residential area of Hove. There is no nursing care provided at the home. District nurses will supply nursing input when needed. The home has a large walled garden at the back of the building that can be enjoyed by both residents and visitors. The home is close to the centre of Hove and within walking distance of the sea front and local amenities. There is nearby access to public transport. There is no parking available at the home, but paid parking is available in adjacent streets. Rooms are located over four floors with a passenger shaft lift to assist residents to access all floors. Although the passenger shaft lift provides access to all floors, residents need to be mobile to access some rooms via a couple of steps. The location of the room available is taken into account when assessing any prospective resident. There are seven rooms that are provided with en suite facilities, including shower facilities. Four of the single rooms are under 10 sq.m. There are five communal toilets located throughout the home and two assisted bathrooms. There is one communal shower. Residents must be mobile to use the shower facilities. There is a good-sized lounge room and a dining room that are both well furnished. There are grab rails placed throughout the home in areas where residents may require some assistance with mobilisation. Weekly fees range between £368 and £650. There are additional fees; hairdressing (£9-£15), Chiropody (£10), newspapers (cost of paper plus delivery) and personal toiletries (at cost). This information was provided to the CSCI on the 31st May 2007. The home currently has a waiting list for prospective residents. A copy of the most recent inspection report is available at the home. Residents/relatives know about the service through social service referrals, word of mouth and from living in the area. Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. It should be noted that following recent CSCI consultation, it was identified that service users prefer to be called people who use services. It was confirmed to the Inspector that people who use this service are called residents. For the purpose of this report, people who use the service will be referred to as residents. This unannounced key site visit took place over seven hours on the 31st May 2007. The Registered Provider/Manager and deputy manager facilitated this visit. The ownership changed to a limited company in November 2006. There have been no management changes in the home with this change. Eight residents, of both genders and over the age of sixty-five years, were spoken with throughout the inspection process and two residents chose to complete surveys. Three residents did not wish to speak to the Inspector and this was respected. One residents care plan was inspected and specific areas of care were viewed in a further two care plans. The Registered Provider/Manager, deputy manager and three staff were spoken with including; a cook and two care staff. One newly recruited staff file was viewed and training records for staff observed. The environment was briefly observed and some individual rooms were looked at. Systems for the administration of medication were inspected and the quality assurance and quality monitoring system in place discussed and viewed. Menus were observed and the Inspector joined the residents for lunch. An Annual Quality Assurance Assessment (AQAA) was sent to the home prior to the site visit. This was to obtain information about the establishment to assist CSCI in the inspection process. There were nineteen residents residing at the home on the day of the inspection. What the service does well: The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home. Prospective residents are provided with opportunities to visit the home prior to moving in to ensure the home will meet their needs. Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 6 Residents were complimentary about the staff working at the home and felt that their personal care needs were being met. Residents felt that their privacy and dignity are respected. Routines of daily living are to the individual’s choice and preference. Activities are provided at the home that is within an individual’s choice, interest and ability. A resident commented ‘if I wasn’t happy, I wouldn’t live here.’ Visitors are welcomed at the home and residents may receive visitors in private. Residents were complimentary about the provision of food at the home and confirmed that an alternative is provided if an individual does not like the main meal on offer. Residents feel comfortable to make complaints, reassuring them that they are being listened to. Residents found their rooms to be comfortable and the home was clean and free from offensive odours. Staff receive training appropriate to their roles to ensure their safety and that residents needs continue to be met. Staff were observed to have a good professional rapport with residents and were heard to be calling them by the preferred term. Some of the comments received from residents were the staff are ‘wonderful’ and ‘I get along well with the staff and can have a good laugh’ Residents and staff benefit from supportive and approachable management within the home. The quality assurance and quality monitoring system implemented ensures that the home is run in the best interest of service users. What has improved since the last inspection? Within the CSCI guidelines, this home is inspected as a new registration. It has changed ownership to a limited company; however there have been no changes within the management structure. The Inspector has visited the home on previous occasions so improvements were able to be observed. It was noted that work has been undertaken to ensure that thorough pre admission assessments are undertaken on all prospective residents and care plans are being developed and reviewed with input from the individual and/or their representative to ensure choice and preference are catered for. Documentation and recording within the home has been improved and has been changed to ensure it is more user friendly, ensuring clear easy accessible information is available to staff and residents. The new deputy manager has implemented many changes since she commenced employment at the home, that all residents and staff benefit from. A staff member commented that they thought the home was good before, but now realises how much better it is. Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 7 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. Wilbury Rest Home DS0000068865.V337545.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 Wilbury Rest Home DS0000068865.V337545.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): 1, 3, 4, 5 & 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home. The pre admission process ensures that only residents whose needs can be met at the home are admitted. EVIDENCE: There is a Statement of Purpose and Service Users Guide available for viewing at the home. These documents have been amended to reflect recent changes in the management structure of the home. Discussions took place with the Registered Provider/Manager and the deputy manager that a copy of these documents are taken and left with prospective residents/representative for them to read about the services and facilities provided at the home. This will ensure that they can make an informed decision if the home can meet there needs and expectations. Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 10 The deputy manager undertakes the assessments of all prospective residents. Pre admission assessments viewed demonstrated that needs of the individual can be met at the home. It was confirmed that there was no one residing at the home from any minor ethnic community, social/cultural or religious groups with any specific needs or preferences. The AQAA identifies that the home is aware of equality and diversity issues and have appropriate policies and procedures in place. Training provided to staff also incorporates equality and diversity issues. It was confirmed that prospective residents are encouraged to visit the home prior to moving in. It was confirmed that it is stated in the contract that the first four weeks are a trial basis, to ensure that the individual is happy living at the home and the home can meet all the individuals needs. Two residents asked both confirmed that they had visited the home prior to moving in. There is no dedicated accommodation for intermediate care. Respite care is available if there is a spare place. Wilbury Rest Home DS0000068865.V337545.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the information provided in the care plans on the assessed needs of residents. Residents are generally safeguarded by the medication procedures in place. Residents’ privacy and dignity are respected. EVIDENCE: The deputy manager has implemented a new care plan format, which staff confirmed is easier and quicker to access information pertaining to an individual’s need. The deputy manager confirmed that care plans are being developed and reviewed with the residents and/or their representative. Care plans viewed provided clear guidance to staff on action to take to meet the needs of individuals. There was evidence that care plans are being reviewed on a monthly basis. Specific areas of care were noted to be reflected Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 12 in individual care plans. There is a key worker system in place that assists in providing continuity of care to residents. Residents spoken with confirmed that they felt all their needs are being met at the home and that staff discuss their care with them. A resident observed to be wearing glasses confirmed that optician appointments are arranged when needed. Another resident spoken with confirmed that eye checks and dental checks are arranged whenever necessary. Both resident surveys received identified that they always received the care and support they need. There is evidence that specialist advice is sought when required. A visiting district nurse spoken with confirmed that they had no concerns regarding the practices within the home and stated staff are very quick to seek medical advice if they are concerned about the well being of a resident. A care plan identified that an individual required to be seen by a chiropodist every six weeks. The last recorded visit noted was in November 2006. It was confirmed by the deputy manager that a chiropodist visits all residents on a regular basis. She confirmed that she will look into the specific visits for this individual and ensure records are up to date. Care plans are currently stored near the dining area. The deputy manager is currently arranging for locked doors to cover the shelving to ensure the storage of information promotes confidentiality. Risk assessments are in place for individuals and these are reviewed on a regular basis. Medication Administration Records (MAR) charts viewed demonstrated that medication is generally being signed for at the time of administration. There were two entries noted where medication has been signed for but not given or given and not signed for. No requirement or recommendation has been made in relation to this as the Registered Provider/Manager or deputy manager can ascertain who was responsible for these shortfalls and address this with the individual directly. One person acknowledged to the Inspector that they were responsible for one shortfall noted. The Inspector appreciated the individual’s honesty and transparency. It was confirmed by the deputy manager that there are policies and procedures in place for all aspects of dealing with medication. The content of these were not read. Records are maintained of incoming and outgoing medication within the home. Residents are provided with an opportunity to self medicate, managed within a risk assessment framework. A resident spoken with, who self-medicates, informed the Inspector that they are aware of the importance of the safe storage of their medicines. Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 13 All residents spoken with confirmed that their privacy and dignity are respected. Staff were observed to have a good professional rapport with residents and were heard to be calling them by their preferred term. It was observed that residents who required additional assistance from staff were assisted sensitively and discreetly. Wilbury Rest Home DS0000068865.V337545.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 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyle within the home is their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. EVIDENCE: Most of the residents currently residing at the home prefer to remain in their rooms. Residents spoken with confirmed that routines and their lifestyle within the home are their own choice. Residents were observed to move freely within the home and some was seen to be enjoying time in the garden. There are regular activities provided at the home and staff and residents spoke positively about being provided with the opportunity to go out into the community more often. There is a notice board near the dining room identifying what activities are on offer. Some of the activities noted to be provided and arranged at the home were: Music for health, music man, Japanese lady who does singing and poetry readings, church service, outings and a mobile library visits the home on a regular basis. Resident surveys Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 15 received identified that there are always activities arranged by the home that they can take part in. One resident stated that she enjoys swimming. The deputy manager confirmed that she has offered to make arrangements for this individual to continue with this activity, however the individual did not wish to pursue this. Visitors are welcomed and encouraged to visit the home. There are no restrictions imposed for visitors. Of the residents that were asked, all confirmed that they are able to receive visitors in private. The AQAA identifies that the home now e-mails a relative of a resident, who lives abroad, to keep them informed of the well being of their parent. Residents generally spoke positively about the food provided at the home. Comments provided ranged from ‘could be better’, ‘quite edible’ to ‘very good’ and ‘lovely’. A couple of residents commented about the blandness of the meat sometimes provided. There was evidence that this is discussed at resident meetings and the home has taken on board comments made and is taking appropriate action to address this. The Inspector enjoyed a tasty roast chicken lunch with the residents. Lunchtime was observed to be a social time for residents and was relaxed and unhurried. The cook confirmed that she is up to date with food and hygiene training and is currently waiting for a vacancy in a National Vocation Qualification level 3 course in food and hygiene. She is provided with a list of residents likes, dislikes/allergies in relation to food. The cook develops a weekly menu and once a week a resident will have the choice of what is provided. One main meal is prepared and if an individual does not like what is on offer, an alternative is arranged. A resident stated ‘if I don’t like the meal, it will be changed.’ Wilbury Rest Home DS0000068865.V337545.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 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents feel comfortable to complain, reassuring them that they are being listened to and that action will be taken, if necessary. Safeguarding Adult procedures and the training of staff ensure residents are safeguarded. EVIDENCE: There is a complaints procedure available at the home and of the residents that were asked, all confirmed that they would know who to speak and feel comfortable to make a complaint and that action would be taken to address their concerns. There have been no complaints made since the last inspection. The deputy manager confirmed that a central record of complaints would be kept when concerns are raised. Staff spoken with confirmed that they are familiar with the procedures to follow in the event of an allegation of abuse being made. Staff confirmed that they have undertaken Safeguarding Adult training. There has been no Safeguarding Adult referrals made since the last inspection. Of the residents that were asked, all confirmed that they felt safe living in the home. One comment received was ‘if I wasn’t happy, I wouldn’t live here.’ Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 17 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and homely environment and are provided with comfortable indoor and outdoor communal facilities. EVIDENCE: Rooms are located over four floors with a passenger shaft lift to assist residents to access all floors. Although the passenger shaft lift provides access to all floors, residents need to be mobile to access some rooms via a couple of steps. The location of the room available is taken into account when assessing any prospective resident. There is a good-sized garden at the rear of the home that residents are able to access. This is often used for parties/barbecues with residents and family members in the summer. The AQAA identifies that it had been difficult to maintain the fishpond to a clean Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 18 and satisfactory state so this has been filled in and built up as a garden. This was done following agreement with the residents. Residents live in a well maintained home and those spoken with confirmed that they were happy with their individual rooms. Rooms were seen to be personalised to reflect the individual’s choice and preference. Hot water outlets are thermostatically controlled and radiators were observed to be guarded. Some of the carpet on the stairs were noted to be wearing thin and starting to fray. The AQAA identifies that the home proposes to replace this carpet within the next twelve months. The home was clean and free from offensive odours on the day of the inspection. A visiting district nurse confirmed that she always found the home clean. The deputy manager confirmed that she has developed a cleaning monitoring form for cleaners to use and ensures she regularly monitors the cleanliness of the home herself. It had previously been recommended that shared hand towels be replaced in communal bathrooms, as this does not promote good infection control practices. Hand towels continue to be used. Management has decided to keep this practice in place and ensure that hand towels are changed at least twice a day. It was observed at inspection that the deputy manager is aware of infection control practices and ensures staff comply with good practices. One resident commented to the Inspector that the clothes washing service provided at the home are ‘fantastic’. Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 19 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 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the number and skill mix of staff on duty and are safeguarded by the recruitment procedures in place. EVIDENCE: Residents spoken with were very complimentary about the staff working at the home. Residents and staff spoken with confirmed that there were sufficient numbers of staff on duty at all times. Staff spoken with stated that they enjoyed working at the home. Some comments received about the staff were; ‘wonderful’, ‘I get along well with the staff and can have a good laugh’ and ‘if you want anything they try to do it for you’. Low turnover of staff assists in ensuring continuity of care is provided. The AQAA identifies that of the twelve care staff employed by the home, seven have obtained National Vocation Qualification (NVQ) level 2 training or above. A newly appointed staff file was viewed that identified that all recruitment checks are undertaken for staff. References are obtained, along with an application form and an enhanced Criminal Record Bureau (CRB) undertaken for all staff, including Protection of Vulnerable Adults (POVA) checks. There Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 20 was no paperwork pertaining to one staff member, who had previously left employment. It was confirmed that all recruitment checks have been undertaken and the deputy manager was already aware of this file not being located at the home. The Registered Provider/Manager will ensure the paperwork is stored at the home. The AQAA received confirms that all people that have worked at the home in the past 12 months had satisfactory preemployment checks undertaken. Staff spoken with stated that they are kept up-to-date with mandatory training and are provided with opportunities to undertake additional training relevant to their roles. The deputy manager has implemented a monitoring form so she can easily monitor when staff are required to undertake refresher courses. Staff spoken with confirmed that if there is a knowledge deficit amongst staff, the Registered Provider/Manager and deputy manager will access relevant training. It was confirmed that three to four staff members are undertaking a twelve-week course on NVQ in dementia. One staff member spoke very positively about the understanding of dementia they are gaining from this course. The deputy manager confirmed that the home has information on the new Common Induction Standards as devised by the Skills for Care sector. All new staff will commence this at the start of employment. Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff and residents benefit from a well managed home and the quality assurance system in place ensures the home is run in the best interest of residents. The health, safety and welfare of residents and staff are promoted and protected so far as is reasonably practicable. EVIDENCE: Staff were complimentary about the management at the home and find the Registered Provider/Manager and the deputy manager very approachable and supportive. It was observed throughout the inspection that both had a good professional rapport with residents. Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 22 The Registered Provider/Manager has owned the home for approximately 11 years. He has been unable to complete the NVQ level 4 in care, as agreed with the CSCI as part of his Registered Manager role, due to other commitments. For the interim, he has employed a deputy manager to assist in the running of the home. This position will be discussed with the Registered Provider/Manager and the CSCI outside of the inspection process. The deputy manager is a registered nurse level 2 with current registration with the Nursing and Midwifery Council. She has had experience of working with older people and has worked in a variety of positions throughout her career. She has almost completed the Registered Manager Award course. It was confirmed that there are clear roles and responsibilities within the home. The deputy manager commenced employment at the home in July 2006 and the Inspector received a lot of positive comments about the changes that she has implemented at the home. A comment received by staff and residents was that ‘she is a breath of fresh air’. Another staff member commented that they thought the home was good before, but now realises how much better it is. There is a quality assurance and quality monitoring system being further developed at the home. The deputy manager confirmed that she proposes to obtain feedback twice a year from residents, relatives, staff and visiting health professionals. Recent results from professional surveys were very positive. Comments received by the home were ‘Excellent standard of care’ and ‘provides a warm and friendly environment, demonstrating sensitivity to residents needs’. It was noted that names were requested or already written on questionnaires. It was discussed with the deputy manager that all people involved with the home are provided with an opportunity to provide anonymous feedback. The deputy manager confirmed that results of the quality monitoring system will be analysed and action taken wherever needed. Results will be pinned to the notice board within the home for all people to see. The deputy manager has implemented many monitoring forms for herself or designated staff to complete, so that she can monitor all practices within the home and ensure staff are meeting the aims and objectives of the home. E.g. First aid box, cleaning within the home and accident records etc. Resident meetings are held every four months and minutes are taken of these meetings. The last meeting minutes were read that demonstrated that all residents appeared happy with their care plan, discussion around the provision of food and all residents were pleased with the activities provided. A garden party was being arranged. Staff meetings are held every three months. Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 23 The AQAA identifies that there are relevant policies and procedures in place and the deputy manager confirmed that she is currently reviewing these to ensure they reflect current guidelines and remain personalised to the ethos of the home. It was confirmed that management is not an appointee for any resident. The home assists two residents with accessing their money from the bank. This money is held in individual bank accounts in the name of the individuals. For one resident, bank statements are regularly sent to a family member. Residents are encouraged and supported to maintain control of their own finances wherever possible. The home will hold personal allowances for individuals. Records viewed demonstrated that records are maintained for each individual regarding their financial transactions and receipts kept. The Inspector was unable to check the running balance of the personal allowances being held at the home due to a running balance not being kept up to date. It was confirmed by the Registered Provider/Manager that he audits these records at the end of every month. The Inspector was informed that the Registered Provider/Manager is the executor of a will but not the beneficiary. It was confirmed that this has been in place for many years. The CSCI does not deem this as good practice. There were some windows noted to be unrestricted. There is documentation in place to state that the home has undertaken an assessment and these unrestricted windows do not pose a risk with the current residents. The home ensures this is kept under review. It was confirmed that all relevant health and safety checks are undertaken on a regular basis. The home reports relevant accidents/incidents to the CSCI as required by regulation. The deputy manager informed the Inspector that a qualified person external to the home undertook a fire risk assessment in April 2005 and this has been regularly updated since implementation. The fire brigade visited the home in April 2007 and no shortfalls were identified. There were no shortfalls identified. A new user friendly fire procedure has been implemented. The content of this was not viewed. Wilbury Rest Home DS0000068865.V337545.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 3 X 3 3 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 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 4 17 X 18 4 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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. Refer to Standard Good Practice Recommendations Wilbury Rest Home DS0000068865.V337545.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wilbury Rest Home DS0000068865.V337545.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. Re-publishing this information is in breach of the terms of use of that website. 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