Inspection on 06/09/05 for Rosemead Care Home

This inspection was carried out on 6th September 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rosemead Care Home 28/04/10

Rosemead Care Home 10/08/09

Rosemead Care Home 10/05/07

Rosemead Care Home 07/11/06

Rosemead Care Home 14/06/06

Rosemead Care Home 07/04/05

Rosemead Care Home 29/09/04

Rosemead Care Home 27/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Wythorpe Rest Home 10-12 Rectory Road Walthamstow London E17 Lead Inspector Rob Cole Unannounced Inspection 6 September 2005 at 10:00am th 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 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. Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Wynthorpe Rest Home Address 10-12 Rectory Road, Walthamstow, London, E17 Telephone number Fax number Email 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 8520 6027 020 8520 6027 sagecare@hotmail.com Mr Saeed Ahmed Ms Dorett May (aka Dee) Buchanan Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7th April 2005 Brief Description of the Service: Wynthorpe Rest Home is registered to provide support and accommodation to fourteen service users over the age of sixty five. The home is situated in a residential area of Walthamstow in the London Borough of Waltham Forest, and is close to shops, transport links and other local ammenities. The home consists of two houses that have been converted in to one, and is built over two floors. The home is privately run. Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 6/9/05 and was unannounced. The inspector had the opportunity of speaking with service users, staff, and the homes proprietor was present for part of the inspection. Despite some areas of good practice, overall the inspector believes that much improvement is needed in the home, to ensure that service users receive high levels of care and support. What the service does well: What has improved since the last inspection? What they could do better: Despite these improvements, there is still much that needs to be addressed, as highlighted by the relatively high number of requirements set during this inspection, thirty three in total, along with two good practice recommendations. Areas of particular concern include the lack of staff training opportunities, the lack of social and leisure activities provided for service users and concerns over health and safety issues such as a poor standard of risk assessing. The greatest area of concern is the low staffing levels in the home, and this must be addressed as a matter of urgency. Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 6 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. Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4 and 5 Although the inspector was satisfied that service users are able to visit the home before making a decision as to move in or not, it is the inspectors belief that to fully enable service users to make an informed choice they must have access to comprehensive and accurate written information about the home, including a Statement of Purpose and Service User Guide. EVIDENCE: The home has a Statement of Purpose and service User Guide in place. Both documents are written in plain English. The Statement contains the aims and objectives of the home and details of the staff team and management. However, the Statement does not accurately reflect the services that the home is registered for. For example, the Statement says that the home can provide nursing care, and that it is registered for adults over the age of 60, when in fact it is registered for adults over the age of 65, and is not registered to provide nursing care. Further, the document is not dated, there is no evidence that it has ever been reviewed, or any indication of when it is next due to be reviewed. Likewise, the Service User Guide is also not dated, and in fact is out of date. For instance it gives the address for complaints as the Registration and Inspection Unit of the London Borough of Waltham Forest, yet this unit has not Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 9 existed since March 2002. The Guide does not contain all information required by National Minimum Standards (NMS), for instance it does not include details of service users individual accommodation. All of this must be addressed. Contracts or statements of terms and conditions were in place for some service users. These included details of services to be provided and fees payable. However, not all service users had been provided with such a document. For example one service user moved into the home in February 2005, yet at the time of inspection they had still not been issued with a contract/statement of terms and conditions. It is required that all service users are given such a document. Although there have been no new admissions to the home since the last inspection, the home has an admissions procedure. This states that pre admission assessments will be carried out, and that prospective service users will be given the opportunity of visiting the home prior to making a decision as to move in or not. Service users will initially move in on a trial basis, after which a placement review meeting will be held. The home does not provide intermediate care. Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 The inspector was satisfied that the home is able to meet the personal care needs of service users. However, lack of access to all relevant health professionals, poor recording of medications and very basic risk assessments lead the inspector to believe that the home is currently not meeting the health care needs of service users as appropriate. EVIDENCE: All service users have care plans in place. Plans are drawn up with the involvement of the service user, their keyworker and the homes manager, and are reviewed on a monthly basis. Plans covered service users social and leisure needs, mobility, medication and personal care needs. Staff informed the inspector that all service users who were placed in the home by a Local Authority are supposed to have an annual review of their care with the Local Authority, but this could not be evidenced for all service users, and must be addressed. Service users all have risk assessments in place, but as at the last inspection these are far from comprehensive. Those seen by the inspector only covered risks associated with service users falling. Further, risk assessments were not dated, and there was no evidence that they are regularly reviewed. It is required that comprehensive risk assessments are in place for all service users, covering all areas of potential risk to themselves and others, and that Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 11 these assessments include strategies to manage and reduce the risk as much as possible. Further, assessments must be dated and subject to regular review. All service users are registered with a GP. Records are maintained of medical appointments, these indicate that service users have access to a variety of health care professionals, including psychiatrists, chiropodists and opticians. However, as at the last inspection the home could not evidence that service users have regular access to dental care. Staff informed the inspector that visiting health professionals will see service users in the sitting room, service users must be able to see visiting health professionals in private. The home makes use of the Continence Advisory Service, who supply advise and continence products. Used continence products are stored in yellow bags in a bin in the garden, but this bin does not have a lid fitted, and this must be addressed in the interests of preventing the spread of infection and protecting service users dignity. The home has a comprehensive medication policy in place, and all staff receive training in medication before they are able to administer it. Records are maintained of medications entering the home and those that are returned to the pharmacist. However, there were inconsistencies between the instructions on some medication labels and Medication Administration Record (MAR) charts. For instance, one service user has been prescribed CO-PROXAMOL tablets. The label on the medication states take daily, yet the MAR charts say take as required. Further, there were no guidelines in place on the administration of medications prescribed on a PRN basis. This must be addressed. MAR charts did not contain a recent photograph of service users, and it is recommended that they do so. Staff were observed to respect service users privacy and dignity, for example staff were seen to knock and wait before entering bedrooms, and service users were given their own mail to open. Service users have access to a telephone to use in private if they so wish. Service users are able to choose their own clothes to wear, and all were appropriately dressed on the day of inspection. Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 and 15 The inspector was not satisfied that service users are provided with appropriate social and leisure opportunities or access to the community due to the current staffing levels. Service users are provided with adequate and nutritious meals. EVIDENCE: In house service users have access to a variety of social and leisure activities, such as TV, video, music and bingo. In the community one service user is supported by their family to attend church. However, there is very little opportunity for service users to access the community, for social and leisure activities or otherwise, due to the current staffing levels in the home. It is required that service users are given the opportunity to access the community in line with their assessed needs and stated preference. Service users are able to receive visitors to the home at any reasonable hour, and can see visitors in private if they choose. Menus are maintained, however, these do not record what if anything service users have for breakfast, and the home must keep a record of all service users meals. On the day of inspection service users were offered a choice of meals, all of which appeared to be appetizing and nutritious. The home has purchased a new oven since the last inspection, the cook informed the inspector that it was a great improvement on the old oven, and was adequate to meet service Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 13 users needs. However, the seal on the fridge was broken, as it was at the last inspection. The inspector noted that the temperature in the fridge was 14 degrees centigrade on the day of inspection, well above safe temperature levels for food storage. The proprietor informed the inspector that he would be purchasing a new fridge for the home within the next two weeks. The home has one fridge, and two freezers, all of which are used for food storage, yet the home only checks and records the temperature for the fridge and one of the freezer, and it is required that both freezers are checked daily. Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17 and 18 The inspector was not satisfied that service users are adequately protected from the risk of abuse. The homes policy on adult protection is not in line with current legislation, and not all staff have received adult protection training. EVIDENCE: The home has a complaints procedure. This was prominently displayed within the home, and made appropriate reference to the CSCI. Service users spoken to demonstrated a good understanding of whom they could complain to if they so wished. However, staff were not aware of the home having a complaints log, and it is required that the home maintains a complaints log, which records any complaints received, along with details of any investigation into the complaints and any outcomes. The home has a copy of the Local Authorities adult protection procedures, and also its own policy on adult protection. However, this was not in line with current legislation, for example it did not make clear the homes responsibility to inform the Local Authority of any suspected abuse. Further, not all staff who work at the home have received training in adult protection issues, and it is a repeat requirement that they do so. The inspector was satisfied that service users legal rights are protected, for example all service users are on the electoral register, and service users spoken to informed the inspector that they are able to vote in elections. Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 and 26 It is the view of the inspector that the home’s environment is generally suitable to meet its stated purpose. Service users are provided with adequate communal and private space, although the home must address the maintenance issues highlighted within the report. EVIDENCE: The home is situated in a residential area of Walthamstow in the London Borough of Waltham Forest, and is close to shops, transport links and other local amenities. The home consists of two homes converted into one, over two floors, with a stair lift between the two floors. There were several instances around the home of decorations that were in a poor state, for instance peeling wallpaper and there was a hole in the wall of the upstairs landing. It is required that the home is kept in a good state of repair and decoration. Much of the homes furniture is coming towards the end of its useful life, and it is recommended that this is replaced. The home has two sitting rooms, a dining room, a conservatory and a garden. The garden was well maintained, with appropriate garden furniture. However, discarded wheelchairs must be Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 16 removed from the garden. The home has two bathroom/toilets and two toilets on their own, and two bedrooms are ensuite. Baths have been adapted, and are accessible to service users. On the day of inspection bathrooms were clean, tidy and free from offensive odour, and all had working locks fitted. All service users have their own bedrooms, these meet National Minimum Standards on size requirements, and have hand basins fitted. Bedrooms have been decorated to service users personal tastes, for example with family photographs, and contained adequate furniture, including table, chairs, wardrobes and chest of draws. However, one bedroom had a strong offensive odour, and this must be addressed. Two bedrooms had no locks fitted, indeed, one bedroom did not even have a door handle, and the hand basin unit in one room was rotting. The home must address these issues. Bedrooms have adequate natural light and ventilation. Heating and lighting was domestic in character, and heating in bedrooms was appropriately boxed in. The home has had an assessment of the premises by a qualified occupational therapist since the last inspection. A report has been made of this visit, which contains several recommendations for the home, as yet none of these have been implemented. It is required that the home implements recommendations made by the occupational therapist where appropriate. The home has a designated laundry room, and laundry facilities are suitable to meet service users needs. Hand washing facilities are situated throughout the home. Staff are provided with protective clothing such as gloves and aprons and the home has policies in place on infection control. Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 It is the view of the inspector that current staffing levels are not adequate to meet service users needs, and that service users are been put at potential risk by these low staffing levels. Further, the home must ensure that staff receive all appropriate training. EVIDENCE: The home has policies in place on equal opportunities and recruitment and selection. Staff employment files are stored in a cabinet in the office. This is not locked, and despite the fact that it contains confidential information about individual staff members, all members of the staff team have access to it at any time, and it is required that confidential information is stored securely. The inspector asked to see several staff files at random. For one staff member, no employment file could be found, although they have been employed at the home for over two years. Other files were checked, and many were found to be missing important information required by the Care Homes Regulations 2001, including CRB checks, passports, birth certificates or photographic ID. All of this must be addressed. Of the ten care staff currently employed at the home, four are working towards relevant NVQ care qualifications. The inspector was informed that it was the homes intention that all staff will be given the opportunity of completing a relevant qualification. Records are kept of staff training. However, these evidenced a generally poor level of training provision, for example for one staff member there was no Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 18 evidence that they had attended any formal training since 2002. Staff spoken to informed the inspector that they had not received any recent training in fire safety, first aid or manual handling, and the records suggested that this was indeed the case. Further, there was no evidence that staff have received any training on working with older people. It is required that staff have access to training as appropriate, and specifically on working with the elderly and all necessary statutory health and safety training. The home provides 24-hour support. There are three staff on the early shift, from 8am to 3pm, and a cook to prepare lunch Monday to Friday. The cook does not work at the weekend, and care staff are expected to prepare meals then. The home has two late shift staff, working from 3pm to 10pm. Some days, there is a third care staff working from 3pm to 6pm. This third shift was not included on the rota on the day of the inspection. Staff informed the inspector that this was because the person employed to work this shift turned up sporadically. The home did not know until any given day whether the person would be coming to work or not, as due to their own child care commitments they were unable to make it into work every day. On days when this person was unable to work, their were no alternative arrangements made to cover their hours, and the home operated with just two staff from 3pm until 10pm. Further, the third staff member does not work at all at weekends, and there is only ever two staff on the late shift then. At the time of inspection the home had eleven service users residing at the home, one of whom was in hospital. Of the ten at the home, one will on occasions require two to one staff support when going to bed. This means that on occasions their will be no staff left to provide support to the other service users when they are supporting the particular service user to go to bed. Not only does this pose a health and safety threat, but it also means that service users are not provided with the full support they need. For example, the two late staff have to prepare meals and snacks for service users, complete any necessary paperwork, administer medications, support service users to go to bed and with other personal care, carry out any cleaning duties required on the shift and deal with any visitors to the home. This leaves very little time for any meaningful interaction with service users, or to support them to access the community. The inspector believes that current staffing levels and arrangements are unsatisfactory, and expressed this view to the home’s proprietor, who was present for part of the inspection. The proprietor informed the inspector that he would ensure that there is always a third member of staff on duty between 3pm and 6pm, including at weekends. It is required that the home is sufficiently staffed at all times to meet service users needs. NB Requirements in this regard have been made on four occasions since the 27/4/04. The CSCI will be taking enforcement action to secure the safety and wellbeing of the service users. Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36,37 and 38 The inspector believes that in several key areas the home needs to improve its management and administration. In particular, quality assurance, health and safety and record keeping must all be addressed. EVIDENCE: There was no evidence that the home has had any Regulation 26 visits since the last inspection. The inspector raised this issue with the homes proprietor during the course of the inspection. The proprietor assured the inspector that he would ensure that monthly unannounced Regulation 26 visits take place, and that a copy of the reports from these visits will be forwarded to the CSCI, and a copy retained in the home. This is required. There are no systems in place to seek the views of service users, their family or staff on the running of the home or the care and support provided. It is required that the home develops quality assurance systems, that include seeking the views of interested parties, to help inform future planning. Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 20 Since the last inspection staff now receive regular formal supervision. Records are kept of supervision, and staff have access to these records. Supervision covers service users issues and performance. As stated, confidential records are not stored securely, and this must be addressed. Further, the home does not keep all records up to date as required. For example, risk assessments and staff meeting minutes are not up to date. The home has various health and safety policies in place, for example on first aid and fire safety. Fire fighting equipment was situated around the house, and was last serviced in July 2005. The fire blanket in the kitchen has been replaced since the last inspection. The home holds regular fire drills, and tests fire alarms weekly. The alarms were last serviced by an engineer on the 5/9/05, the engineer found that several call point alarms were not working properly, and the home must address this. The home had a well stocked first aid box, and COSHH products were stored securely. The home had in date certificates for gas and electrical installation safety. However, as at the last inspection there was no evidence that PAT testing has been carried out in the past twelve months, and this must be addressed. There was no evidence that the home tests and records hot water temperatures used for personal care. It is required that they are tested at least weekly, to ensure that they are 43 degrees centigrade. Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 x 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 2 3 2 3 2 3 3 STAFFING Standard No Score 27 1 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 1 x x 1 x x 3 1 2 Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 22 YES 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 OP8 Regulation 13 Requirement Timescale for action 31/12/05 2. OP18 13 3. OP29 19 4. OP38 13 The registered person must ensure that all service users have access to appropriate health care, including regular access to dental and eye care, and that records are maintained of all appointments. (Timescale 30/6/05 not met) The registered person must 31/12/05 ensure that all staff who work in the home are aware of their responsibilities with regard to adult protection issues, and are familiar with any relevant policies and procedures, and that they receive appropriate training in adult protection issues. (Timescale 30/6/05 not met) The registered person must 31/12/05 ensure that all documentation required by Schedule 2 of the Care Homes Regulations 2001 is in place for all staff working in the home. (Timescale 30/6/05 not met) The registered person must 31/12/05 ensure that the home tests and records on a weekly basis all hot water temperatures used for personal care to ensure they do not exceed 43 degrees Celsius. G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Wythorpe Rest Home Page 23 (Timescale 30/6/05 not met) 5. OP27 18 The registered person must ensure that sufficient staff are on duty at all times to meet the assessed needs of the service users. (Timescale 30/6/05 not met) The registered person must ensure that risk assessments are undertaken for safe working practices and for service users undertaking any activities that involve risk taking. The risk assessments must be placed on service users files and be subject to regular review. (Timescale 30/6/05 not met) The registered person must ensure that the Service User Guide contains all information required by National Minimum Standards. (Timescale 30/6/05 not met) The registered person must ensure that written guidelines are in place for the administration of all medications prescribed on an as required basis. (Timescale 30/6/05 not met) The registered person must ensure that the home provides appropriate social and leisure activities in line with service users assessed needs and stated preferences. (Timescale 30/6/05 not met) The registered person must ensure that the home has kitchen appliances, including fridges, that are in full working order and adequate to meet the needs of service users. (Timescale 30/6/05 not met) The registered person must ensure that all staff receive all required statutory health and G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Refer to NB on page 19. 6. OP7 OP38 13 31/12/05 7. OP1 5 31/12/05 8. OP9 13 31/12/05 9. OP12 16 31/12/05 10. OP15 23 31/12/05 11. OP30 13 31/12/05 Wythorpe Rest Home Version 1.40 Page 24 12. OP33 26 13. OP38 13 and 23 14. OP1 4 15. OP2 5 16. OP7 15 17. OP8 12 18. OP8 12 and 13 19. OP9 13 safety training including fire safety, moving and handling, first aid and food hygiene. (Timescale 30/6/05 not met) The registered person must ensure that monthly Regulation 26 visits are carried out, and that a copy of the report of these visits is sent to the CSCI and a copy retained in the home. (Timescale 30/6/05 not met) The registered person must ensure that the home undertakes Portable Appliances Testing at least once every tweleve months. (Timescale 30/6/05 not met) The registered person must ensure that the homes Statement of Purpose is in line with National Minimum Standards, and that it is dated and subject to regular review. The registered person must ensure that all service users have a signed written contract/statement of terms and conditions in line with National Minimum Standards. The registered person must ensure that all service users who are placed by a Local Authority have a review of their care needs at least annually involving the Local Authority. The registered person must ensure that service users are able to see visiting health proffessionals in private. The registered person must ensure that used continence products are stored in a container with a lid attached. The registered person must ensure that instructions on medication labels are consistant with instructions on MAR charts, and that both are in line with the 30/9/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 25 20. OP15 17 21. OP15 13 22. OP16 22 23. OP18 13 24. OP19 23 25. OP20 23 26. OP22 23 27. 28. 29. OP24 OP24 OP24 23 23 23 prescribing instructions of the medical practitioner who prescribed the medication. The registered person must ensure that the home maintains a record of all meals offered to service users. The registered person must ensure that the temperature for all fridges and freezers in the home are checked and recorded at least once a day. The registered person must ensure that the home keeps a record of all complaints recieived, and any investigations and outcomes. The registered person must ensure that the homes adult protection procedures are in line with current legislation. The registered person must ensure that all areas of the home are decorated to a reasonable standard. The registered person must ensure that discarded wheelchairs are removed from the homes garden. The registered person must ensure that the home implements the recommendations made by the occupational therapist on their visit to the home on the 20/5/05 where appropriate. The registered person must ensure that all bedrooms are free from offensive odours. The registered person must ensure that all bedroom doors have locks fitted. The registered person must ensure that the rotting hand basin stand in one of the bedrooms is replaced or repaired. G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 Wythorpe Rest Home Version 1.40 Page 26 30. OP30 18 31. OP33 24 32. 33. OP37 OP38 12 13 The registered person must ensure that all care staff receive appropriate training on working with older people. The registered person must ensure that the home has quality assurance systems in place which include seeking the views of service users, to help inform future planning. The registered person must ensure that all confidential records are stored securely. The registered person must ensure that all call point alarms are in full working order. 31/12/05 31/12/05 31/12/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP19 Good Practice Recommendations It is recommended that MAR charts contain a recent photograph of the service user. It is recommended that the home gives consideration to replacing the furniture in the home that is coming towards the end of its useful life. Wythorpe Rest Home G56 G06 S7217 Wynthorpe Rest Home V246037 060905 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection Gredley House 1-11 Broadway London E15 4BQ 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. 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