Inspection on 12/07/06 for Fairburn Chase

This inspection was carried out on 12th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

Other inspections for this house

Fairburn Chase 24/04/07

Fairburn Chase 09/01/06

Fairburn Chase 04/07/05

Fairburn Chase 01/06/05

Fairburn Chase 11/11/04

Fairburn Chase 29/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Wheldon View Care Centre Wheldon View Wheldon Road Castleford West Yorks WF10 2PY Lead Inspector Gillian Walsh Key Unannounced Inspection 12th July 2006 10:00 X10029.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 Wheldon View Care Centre DS0000006266.V304297.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 and Care Homes for Adults 18 – 65*. 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. Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wheldon View Care Centre Address Wheldon View Wheldon Road Castleford West Yorks WF10 2PY 01977 559703 01977 517664 wheldonview@exemplarhc.com 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) Wheldon Health Care Limited Ms Michelle Julie Mehta Care Home 76 Category(ies) of Old age, not falling within any other category registration, with number (76), Physical disability (29), Terminally ill (2), of places Terminally ill over 65 years of age (2) Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No more than 20 service users with nursing care needs to be admitted to the general unit (first floor) That Michelle Mehta undertakes the Registered Managers award. Date of last inspection 9th January 2006 Brief Description of the Service: Wheldon View is situated on the outskirts of Airedale village and Castleford town centre with limited access to local shops although this is partly compensated for by the home having use it’s own minibus. It is a purpose built home for 76 residents, 47 of whom are older people with the remainder of places being for younger adults with a physical disability. The home is registered for personal care and nursing beds. All bedrooms are single and offer en-suite facilities. There is a well-tended central forecourt garden for residents to sit out in the good weather. A team of qualified nurses, care assistants and ancillary staff work at the home and the local doctors and their Primary Health Teams support them. The proprietor is Wheldon Health Care Limited. The manager informed the Commission for Social Care Inspection on 12/07/06 that fees currently range from £359 to £1000 per week. Additional charges include hairdressing, private chiropody and newspapers. Information about the home is available to potential residents via the Statement of Purpose, Service User Guide and the last inspection report, all of which are available in the home’s reception. Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this full inspection, three inspectors from the Commission for Social Care inspection (CSCI) undertook a visit to the home. The visit started at 10am and finished at 6.30pm. Alongside this, the service provider was asked to complete a pre-inspection questionnaire which was returned prior to the visit. Questionnaires were sent to residents, their relatives, visiting professionals and GPs. Of the 11 resident questionnaires sent out, 6 were received back. Of the 8 relatives’ questionnaires sent out, 6 were returned. Of the 4 General practitioner questionnaires sent, 1 was returned, and of the 8 social worker questionnaires, 2 were returned. Relevant comments made within these questionnaires have been included within the body of the report. In writing this report, information and evidence was not only obtained by way of visiting the home but also from notifications and information sent to CSCI and from the last CSCI inspection reports which included a random inspection of the home in response to a complaint made on 19th June 2006. In gathering evidence, CSCI undertook case tracking, reviewed documentation, sought feedback from residents and their families, staff, the home’s manager and registered person and other relevant stakeholders, and undertook relevant observations and discussions appropriate to needs of the residents, taking into account their needs and communication needs. The inspector would like to thank residents, their relatives and staff for their time and assistance during this inspection. What the service does well: Residents said that most staff are kind and attentive to their needs and the home provides a pleasant environment for residents. The newly appointed operations director is currently auditing all of the systems within the home in order to obtain an overview of where improvements are needed to ensure better outcomes for residents. Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP3 and YA2. OP6 (intermediate Care) not applicable to this service. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Pre-admission assessments are completed and have recently been improved by the inclusion of an assessment of the person’s social and psychological needs and personal goals and aspirations. EVIDENCE: Pre-admission assessments were seen for residents on both the older people’s and younger adults’ units. Physical needs had been fully assessed but there was little evidence that potential residents’ social and psychological needs are fully considered or that personal goals and aspirations (particularly in relation Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 9 to younger adults) are discussed prior to admission. The responsible individual said that new documentation has now been produced for the purpose of preadmission assessments which does now include all of the above. The home manager confirmed this and said that she has begun to use this documentation. Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): OP 7, 8, 9, 10 and YA 6, 9, 10, 16, 18, 19 and 20. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Care plans concentrate on physical needs and give little indication of the promotion of residents’ abilities, independent living skills and personal goals or of decisions they make about their lives. Evidence is available to show that residents’ healthcare needs are met but shortfalls in medication systems have potential to put residents at risk. Staff do not always protect residents’ dignity. Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 11 EVIDENCE: Each resident has a care plan file and a selection of these were seen. Care plan files contain a good deal of documentation which includes various assessments and sections relating to the life history and family of the resident. Positively, the majority of care plans give good detail of residents’ healthcare needs, based on completed assessments, and of how these needs should be met. Care plans also include some information about residents’ personal preferences within their daily lives and about how they choose to receive their care. In some instances better detail would be helpful to staff in ensuring that the care they were delivering was the care expected or requested by the individual concerned. One of the files seen on the older people’s unit included a wound assessment which stated that the resident concerned had a grade three pressure sore but a care plan had not been developed in relation to this problem. Another care plan talked about provision of correct incontinence pads but gave no indication that the person suffered from incontinence. Although nutritional assessments are being completed, these are not always being followed up appropriately. One nutritional assessment detailed that the resident was losing weight inappropriately but no care plan had been developed in this regard. With particular reference to the younger adults unit, none of the care plans seen concentrated on promotion of ability, independent living skills and personal goals but rather focused on managing disabilities. Risk assessments generally are being completed but this had been not been done for one resident who had been identified as being at risk of choking or in relation to the promotion of independent living skills. Evidence is available within care plan files that residents or, where appropriate, relatives are involved in care planning and review. Evidence is also available within care plan files to show that residents’ health care needs are met either through staff at the home or through community services such as GPs, district nurses, dentists etc. One person said that they missed the physiotherapy they had previously received and felt that ongoing physiotherapy would help them. Since the last full inspection, a further 3 visits have been made to the home to ensure that processes have been introduced and followed by staff to ensure that safe systems regarding the receipt, storage administration and disposal of medication are maintained. On this occasion, anomalies were found in five of the ten medications checked. All of the anomalies were that the balance of medication available did not tally with the recordings on the Medication Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 12 Administration Record (MAR) sheets and one MAR sheet indicated that the staff had made the decision to give the medication on a PRN or “as required” basis rather than twice a day as prescribed. The nurse in charge confirmed that they were giving the medication on a PRN basis. Most of the residents spoken with said that they were happy with the way most of the staff cared for them and with their attitude toward them. One person said that they did not think that some staff appreciated the indignity felt by residents when they suffered incontinence as they kept being told “it doesn’t matter” and staff failed to supply the correct incontinence aids. Another resident said that some staff do not speak to them at all whilst supporting them with intimate care needs. One resident was observed to call for staff as they needed some care intervention. The care assistant came to the room accompanied by a young person undertaking work experience at the home. As the carer gathered equipment, the inspector asked the resident if they were happy with the work experience person remaining in the room while his care needs were attended to. The resident told the inspector that they did not want the procedure to be watched this person. The resident’s wishes were only obtained and met on this occasion due to discussion with the inspector. Concern was raised with the manager that, at a mealtime, staff were overheard to refer to people who required a soft diet as “the softs”. All of the residents spoken with said that staff knock on their bedroom doors before entering and said that the majority of staff are respectful of their need for privacy. Concern was expressed to the manager and the responsible individual that details of one resident had been included in another resident’s care plan file and also that police officers who were visiting the home to investigate a previous incident had been given access to care plans and drug records. Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 12, 13, 14, 15 and YA 11, 12, 13, 15 and 17. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Outcomes for residents in relation to activities (particularly age appropriate), recreation needs, community contact and opportunities for personal development are poor. Arrangements for maintaining contact with relatives and friends are adequate. Not all residents feel that they have choice and control over their lives. Meals on the whole are adequate and nutritious but routines around mealtimes and choice of food are not fully meeting with residents’ needs and choices. Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 14 EVIDENCE: During the morning, a small group of residents from the older people’s unit were seen to be enjoying a game of bingo led by a volunteer working at the home. Other than this, no structured activity was taking place. One resident on the older people’s unit said, when asked what they were doing that day, ”Dying of boredom” and another wrote in a comment card “there is virtually no organised activities to do day or night”. None of the residents on the younger adults unit attend college or undertake any kind of work or training and there is no evidence available, either within care plans or from speaking with residents, that any discussion takes place with residents about their needs or aspirations in this area. One person said that they would like the opportunity to attend a day centre where they could be supported toward their goal of living a more independent life. Very little is available within the immediate neighbourhood but residents do occasionally go out to a nearby shopping and leisure centre. One younger person said that they would like the opportunity access some evening activities or even nightlife within the local area. One resident said how the activities organiser has arranged for the access bus to enable people to attend the local church. The younger adults unit has a games room where computers are also available for residents and one person was seen to be attending to their affairs “on line”. Residents’ contact with families and friends is encouraged by staff and visitors spoken with said that they were happy with arrangements for them to visit. Some people also are enabled and assisted by the home’s staff to visit their friends and relatives in their homes although this can be restricted to the availability of the home’s mini bus. Some evidence is available within care plans that residents’ choices and preferences with regard to daily living are sought and documented although this is not always reflected in daily records. Some residents spoken with, particularly on the younger adults unit, said that staff did not always meet with their choices for bathing and rising and retiring times although they felt this was more to do with the home being under staffed than lack of consideration. Most of the residents said that they were happy with the meals provided and that recently more variety has been introduced including beer and sherry etc. One person said that when “some staff” are on duty, drinks are not served to residents in their rooms other than at meal times. Only one person said that they did not enjoy the meals as they found them to be very traditional meat and veg meals and, as a younger person, would prefer meals such as pasta. This person also said that they would welcome the opportunity to receive support and education to enable them to cook their own meals. Another person Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 15 said in a comment card that they missed the fish and chip suppers that used to be held at the home. The lunchtime meal on the older persons’ unit was observed. Staff have a routine where residents who require a soft diet are served their meals first and these meals are delivered from the kitchen on a trolley plated up. The dessert that day for people needing a soft diet was milk pudding, which was supplied from the kitchen in a jug covered with cling film. Only a few people were receiving a soft diet and they were either being served their meal in their room or at a table on their own in the dining room. This meant that people did not have any social interaction at meal times and, negatively, were referred to by staff as “the softs”. One person said within a comment card, “meal times are a very strict routine time, making the home more like an institution than a home”. Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16, 18 and YA 22 and 23. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The systems and procedures operated by the staff at the home make sure that service users and their carers are made aware of how to raise issues and complain, giving them confidence that they will be listened to and their views acted on. There are satisfactory systems in place that endeavour to protect service users from abuse and harm. EVIDENCE: Since the last full inspection, nine complaints/concerns have been received by the home and one complaint has been made to the Commission regarding staffing levels at Wheldon View. Documentation is available to show that all complaints have been dealt with appropriately and thoroughly through the home’s complaints procedure. Staff at the home have knowledge of, and access to, Wakefield Metropolitan District Council’s adult abuse policies and procedures and have referred appropriately when required. The home also follows its own company’s policies Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 17 and procedures for protection of vulnerable adults. Staff training records show that staff have received training in this area. Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 19, 20 and YA 24 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is clean, pleasant and hygienic with comfortable communal areas and appropriately furnished and personalised bedrooms. EVIDENCE: Generally the home is well maintained and provides a comfortable environment for residents. Push button door openers are fitted to give disabled access to Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 19 and from the home. The majority of residents’ rooms have been personalised and contain equipment necessary to promote independence. Hygiene standards are good and the home appeared clean and tidy. None of the comment cards received indicated any problems with the cleanliness of the home. Since the last full inspection, an anonymous complaint raised to the Commission included information that residents at the home were not happy with the fact that the residents’ smoking room on the older people’s unit had changed use to an activities room and, therefore, all residents who wish to smoke were using the smoking room on the younger adults unit. The complaint was that some people were not happy with this situation. No evidence has been found, either in a random visit made to the home or in this full inspection, that residents have been adversely affected by this change. Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 27, 28, 29 and 30 and YA 32, 34 and 35. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service and is as a result of comments made by residents about the lack of staff availability. Residents do not feel that staff are available in sufficient numbers to meet their needs. Induction, training and recruitment processes are generally good although the manager must ensure that staff are trained to meet specialist care needs of residents in the home. EVIDENCE: Since the last full inspection, the Commission for Social Care Inspection received an anonymous complaint regarding staffing levels at Wheldon View. In response to this, a random inspection was made of the home on 19th June 2006 to look specifically at this issue. From information gained from speaking Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 21 to staff and residents, the complaint was upheld. Staff, residents and relatives continued to express their concern about staffing levels through comment cards and through conversations during the visit. One resident said in a comment card that they are very dependent on staff but “cannot always get this done at weekend as there is always a shortage of staff”. Another resident wrote “The home is always short staffed. I’m lucky if I can get a shower once a week”. Three of the six relatives’ comment cards received by the Commission said that there are not enough staff on duty, with one person saying there are “never” enough. Two residents told the inspector that they “dread weekends” as they know there will be staff shortages. Copies of duty rotas were seen and discussion took place with the manager about these issues who felt that the problems may be due more to staff deployment than actual numbers. One resident said that there were many occasions when they were not supported to get up from bed in a morning before their preferred time of 10.30 am and that it could be lunchtime before staff were available to help them. Records show that all staff receive a satisfactory induction before commencing work at the home. Mandatory training is organised on a continuous basis and a training matrix is maintained by the manager to demonstrate when training has been undertaken and when it is due. NVQ training is also ongoing with 22 of the current care staff now holding the award. One resident said that, on one occasion, they had had to wait for over 12 hours when their supra pubic catheter had come out and staff on duty were not trained in supra pubic catheterisation. This had caused the resident a lot of pain and discomfort. Discussion took place with the registered person and the manager about ensuring that sufficient staff received training in procedures necessary to residents in the home. From discussion with residents and staff, it is unclear how the nursing staff supervise and support the staff team. The general perception is that qualified staff do the medications and the paperwork but are not always involved in the direct delivery of care. The registered person said that she was aware of this and was working with staff to develop a better team approach. Staff files were seen and contained documentation to show that recruitment policies and procedures to protect residents’ safety are followed. Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 31, 33, 35, 38 and YA 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is managed by a person with suitable management skills to run the home. Processes for staff supervision are poor, both formally and informally. Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 23 The systems operated by the home ensure that the health, safety and welfare of people living and working at the home are promoted and protected. EVIDENCE: The home’s manager is a registered nurse with many years’ experience of care in a residential setting. She has commenced studying for the registered managers award. For quality monitoring purposes, satisfaction surveys are sent out on an annual basis via the home’s head office to gain the views of residents, staff and other stakeholders. Several residents said that they had completed these and that the registered person had discussed with them areas of dissatisfaction and suggestion to ensure that their views are an integral part of the development of the home. In addition to this, the registered person is conducting an audit of all departments within the home in order to assess standards. Staff and resident meetings are held on a regular basis and minutes of these meetings were seen. Small amounts of personal allowances are held in the home’s safe at the request of some residents. The amounts and the documentation relating to this money were checked and found to be appropriate and accurate. The registered person said that currently only the home manager is trained in, and capable of delivering, structured supervision for all staff. As a result of this, staff are not receiving supervision at a minimum of six times each year. Documentation relating to health and safety practices and systems within the home were checked and found to be appropriate. Wheldon View Care Centre DS0000006266.V304297.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 3 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 1 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 N/A 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 1 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 1 37 X 38 3 Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? 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 YA6 Regulation 15(1) Requirement Timescale for action 31/08/06 2. OP9 YA20 13(2) 3. OP10 YA18 4(a) Care plans must be developed to ensure that all residents’ health and social care needs are met. This must include development of care plans where a resident has a pressure sore and where a nutritional assessment indicates weight loss. 12/07/06 The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medications received into the care home. This requirement has been brought forward from the previous three reports. The original timescale was 29 June 2004. Suitable arrangements must be 31/08/06 made to ensure that the home is conducted in a manner, which respects the privacy and dignity of service users. This requirement has been brought forward from previous reports. The original timescale was 17 DS0000006266.V304297.R01.S.doc Version 5.2 Wheldon View Care Centre Page 26 November 2004. 4. YA12 YA13 YA14 OP12 16(2)(m)(n) Residents must be consulted about their social and recreational interests and arrangements must be made to enable residents to take part in activities, education or employment as appropriate to their needs and aspirations. 18(1) The registered person must ensure that at all times suitably qualified staff are working in the care home in such numbers as are appropriate for the health and welfare of service users. This was made as an immediate requirement of the visit made on 19th July 2006. 18(2) All persons working in the care home must receive appropriate supervision. 30/09/06 5. OP27 YA33 12/07/06 6. YA36 OP36 30/09/06 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. 3. 4. Refer to Standard OP3 YA2 OP14 YA7 YA6 YA10 Good Practice Recommendations Pre-admission assessments should include details of prospective residents’ social and educational needs and personal aspirations. Care plans should give details of decisions residents have made in relation to their care and lifestyle. Care plans should reflect individuals’ aspirations and goals and demonstrate evidence of positive planned interventions, therapeutic and rehabilitation programmes. The responsible individual should ensure that information about residents is maintained confidentially within their own file and should also take advice about police access to confidential records. Staff training needs should be identified in relation to DS0000006266.V304297.R01.S.doc Version 5.2 Page 27 5. YA35 Wheldon View Care Centre meeting residents’ needs. Wheldon View Care Centre DS0000006266.V304297.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 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. Wheldon View Care Centre DS0000006266.V304297.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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