Inspection on 10/06/05 for St Wilfrid`s Hall Nursing Home

This inspection was carried out on 10th June 2005.

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

St Wilfrid`s Hall Nursing Home 09/08/07

St Wilfrid`s Hall Nursing Home 19/06/06

St Wilfrid`s Hall Nursing Home 13/12/05

St Wilfrid`s Hall Nursing Home 31/01/05

St Wilfrid`s Hall Nursing Home 04/05/04

St Wilfrid`s Hall Nursing Home 10/02/03

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE St Wilfrids Hall Nursing Home Foundry Lane, Halton On Lune, Lancaster, Lancashire LA2 6LT Lead Inspector Joy Howson-Booth Unannounced 10 June and 17th June 2005 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. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Wilfrids Hall Nursing Home Address Foundry Lane, Halton On Lune, Lancaster, Lancashire, LA2 6LT 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) 01524 811229 01524 811949 Latham Lodge Limited CRH Care Home 41 Category(ies) of OP Old Age 41 registration, with number of places St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home must employ at all times a suitably experienced and qualified manager who is registered with the Commission for Social Care Inspection. 2. The home is registered for a maximum of 41 service users in the category OP (Older Persons). 3. The registered manager must obtain National Vocational Qualification Level IV in Management by 31 December 2005 Date of last inspection 31st January 2005 Brief Description of the Service: St Wilfred’s is one home within a larger group of homes owned by Lathom Lodge Limited. St Wilfred’s is a long-established care home which can be found in the small village of Halton-on-Lune, some 4 miles North of Lancaster. Previously a private accommodation for the local Church Vicar, St Wilfred’s became a nursing and residential home a number of years ago. The home is set in its own extensive grounds which are accessible to both service users and visitors alike. The provision of garden furniture and canopies makes the gardens a very pleasant place to sit and view the surrounding countryside in the warmer months.The home has its own transport which is used to take residents out. Local facilities and amenities would be accessible for those residents who are more mobile. The home has the services of a Divertional Therapist. The home is a three-storey building, with resident accommodation over the ground and first floors. The provision of an extension a number of years ago provides additional accommodation for residents. There are three lounges, including a quiet lounge and one previously used as a “smoking room”. There is a separate dining room which is used by the residents. It is understood that the Company still has plans to build a conservatory onto the home and this would be a welcome facility. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 10th June and 17th June 2005. The inspection lasted for one and a half days and involved speaking with a number of residents and staff, viewing documentation and a tour of the home. In addition to this, a number of visiting relatives/friends were spoken with. Three comment cards were received, along with a personal phone call from an visitor whose relative has since moved to another home. Following concerns raised at this inspection, two letters were sent to the Regional Manager outlining these concerns and requesting prompt action be taken. On 21 July 2005 a meeting took place with the Regional Manager and Acting Manager and it was noted that the majority of the concerns raised either have or are being addressed. These are contained in full in the body of this report. The lack of permanent manager has had an effect on the running of the home and it is hoped that the new manager, expected to be in place in the next few weeks, will bring stability and direction to the home. What the service does well: What has improved since the last inspection? There has improvements to the quality of meals provided at the home. A new drainage system has been installed in the extension of the home. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 6 What they could do better: More information needs to be gained about the needs of any person who may wish to come into the home. The form the home uses is not always fully completed. The plans of care that tell staff about the needs of the residents should be more up to date and give more information/instructions. Areas that look at individual residents health need to be better recorded – including meals provided, weight records, skin care, etc. Where there are areas of care that may pose a danger, for example, when a client may need to be physically moved, the home needs to consider these and make sure the concerns and any instructions are written in an understandable way on a form which is then reviewed on a regular basis. There are training courses that would help the named person to become more familiar with risk and help to make sure any written information or instructions are clear. The new manager should meet with the chef to talk about his ideas and suggestions about meals. Residents don’t always feel that their concerns are treated seriously. The manager of the home must make sure that the home is kept clean, tidy and provides a pleasant place for the residents to live in. A plan which gives information over when the carpets, furnishings and furniture will be replaced/repaired needs to be sent to the Commission. The manager must confirm that health and safety issues and the long-term fire plan have been put in place. Residents have said that they are not always given a bath when they ask. Sufficient staff need to be on duty to make sure this does not happen. Criminal Record Bureau checks for foreign staff must be sent for. At present, St Wilfred’s Hall does not have a permanent manager, although a new manager will be in place in the next few weeks. This lack of manager has meant the home has not been well managed. When an accident happens, the manager must make sure that there is nothing that could be done in the future to make sure it doesn’t happen again. When an accident or something happens to a resident the Commission must be told about this. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 7 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. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 5 There are good arrangements in place which mean that prospective residents can visit the home and are provided with information. The needs of the residents and information about their individual lifestyles is not obtained in full before they come into the home which means the home is not clear that all areas of need can be met. EVIDENCE: From case files examined for three recently admitted residents it was seen that the formal pre-admission assessment form had been used. However, these were not fully completed – for example one did not include routines for rising and retiring, social and spiritual information. Other care requirements were reasonably comprehensive, although the preadmission form should indicate that an assessment has taken place for all the areas on this form as some areas are left blank and it is unclear whether these have been assessed or not. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 10 Discussions with two visiting relatives confirmed they had been able to look around the home to see the facilities and were aware that their relative had a four week trial period at the home. They also confirmed they were given written information regarding the homes services and facilities. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 8 Some progress has been made over care records, but care practices lack consistency which means health and welfare needs are not always met. EVIDENCE: From the five case file examined it was found that there care plans in place. Generally these provided good information over individual residents needs but tended to concentrate on the practical care side. It was noted that some information on pre-admission assessments had not been transferred into the care documents – for example, one resident had a history of falls which had not been included in the risk assessment which would have taken the resident into the next band of “high risk”, another resident apparently uses a sheath at night time but again this had not been included in the care plan and a further resident needed their food cutting up which had not been included in the care plan. Nursing assessment and intervention charts (for example, Braden Scale for Predicting Pressure Sore Risk and Manual Handling Risk Assessment) were completed with scores of 21 and 10 respectively but it was not clear what St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 12 these scores mean or the action to be taken as a result. However, one weight record examined noted on 15.5.05 a weight of 7 stone 3 lb – a loss of 7lb with a recommendation to reweigh but this had not been done. One resident apparently has cot sides in use but there was no consent form in their care file. Another resident is assessed as needing a pressure cushion to sit on during the day but this information is not in their care plan. One care plan was good in that it included the fact that the resident was partially sighted and incorporated environmental and personal safety needs. Records for health care were seen and discussions with residents confirmed they feel their healthcare needs are being met. Residents and relatives/visitors spoken with expressed concerns that they feel their welfare is not always met. For example, six residents stated they had not had a bath on a regular basis, one resident had not been given a breakfast on two occasions and one resident had not been given their tea. Comment was made by one visitor and one relative that they had had to ask on more than one occasion for their friend and relative to have their hair washed and be given a shave. These comments were provided in a separate letter following the inspection and action was required to be taken to address these as a matter of priority. During the follow up meeting the Regional Manager and Acting Manager confirmed that the concerns regarding bathing and personal care had been addressed with the staff team who are now provided with clear directions for care tasks during the day. In addition to this, practical steps have also been taken – for example, the shower room has been adapted and a new shower chair obtained. Records are now in place and used by staff to confirm when care tasks have been undertaken. Confirmation was given that personal preferences (e.g. one resident wishes to have a shower every day) are now being met. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 Meals are balanced, nutritious and of good quality giving the residents both choice and variety. EVIDENCE: Residents spoken with were very pleased with the meals provided and were happy with the quality and quantity provided. Residents spoken with particularly enjoyed the “theme” menus (i.e. the Italian day). Menus were seen and evidenced that residents have a choice of meals. Further advice and guidance provided over the need to record in more detail meals taken by individual residents. Suggestions made by residents during this inspection were passed onto the Chef – for example, a number of residents would like more salads. The meal taken at lunchtime was excellent, although the temperature of the food was warm rather than hot. This is something the Chef is aware of and is addressing. A number of residents have to be supported by staff and this is done separately in another lounge. It is suggested that this is something the new St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 14 manager (once in post) can review as this means these residents do not get a change of scenery or location during the day and the remaining meals have to be kept warm which must affect their quality, freshness and overall temperature. The chef is relatively new in post and, from discussions, is very keen to develop the meals provision to “hotel standard”. He has a number of ideas that would improve the service – for example a “sweets trolley” and is intending to meet with the new manager to discuss his ideas further. It was confirmed that training for the chef is being organised and will include – Intermediate Food Hygiene and Nutrition. The dining room is laid out in a pleasant way with the meals being served in a courteous and unhurried manner in a relaxed atmosphere. Residents commented that they did not enjoy the music being played on the radio at the time – which was modern and described by one resident as “bang, bang, bang”. It was confirmed that at a recent staff meeting the staff themselves felt that it would be more appropriate to have relaxing music on whilst residents were eating particularly for those who require support. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 15 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 Complaints are not handled properly which means that residents are not confident that their concerns will be listened to, taken seriously and acted upon. EVIDENCE: The current complaints file was examined and evidenced that action is taken when serious concerns arise but nothing is recorded for concerns raised by residents in the home. Discussions with residents were of concern as their issues do not appear to be being dealt with. One resident said that when she had expressed concern that she did not want to be provided with a bath by a male carer the member of staff said that there was no option. Another resident said that when they had raised concerns about a missing item of clothing the member of staff had said “it will turn up”. In the daily diary for one resident it is written “unhappy with the care provided this morning”. There is nothing regarding this in the complaints file or any evidence that action had been taken to find out what was wrong or any action taken. At the follow-up meeting with the Regional Manager and Acting Manager it was confirmed that a training course in Customer Care has been organised and, through their own discussions with staff, both managers have identified that staff are unclear what action must be taken when a resident expresses any dissatisfaction. It is intended that the training on Customer Care, along with in-house instruction and guidance from the Acting Manager will enable staff to recognise, record and act on concerns in the future. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 16 In addition to this, evidence was seen that two residents meetings have been held where suggestions, comments have been noted and are being acted on. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 23, 24, 25 and 26 Limited improvements have been made to the home. The standard of décor within this home is adequate with little evidence of planned refurbishment taking place and outstanding matters do not provide the people living in the home with a safe, comfortable and well maintained environment. EVIDENCE: A tour of the home took place during this inspection and a number of issues regarding cleanliness and minor maintenance were noted. These have been addressed in a separate letter. The indoor facilities within the home are potentially very good, although some of the décor and furnishings are in need of replacement. For example, the dining room curtains are torn and this and other carpets needs to be replaced. A number of commodes are rusty and do not provide a positive aid for the residents to use. Despite requests in previous inspection reports, the Company has failed to provide a refurbishment programme. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 18 Individual rooms were seen to have been personalised with treasured possessions. One room still requires carpeting. Each resident has their own room with separate ensuite facilities and again minor maintenance issues were noted. Most rooms at the home are single occupancy, although there are two double rooms being used by two married couples There are a range of toilet and bathing facilities within the home but again these need to be made more homely and comfortable rather than their present appearance which is clinical and sparse. The outdoor facilities are excellent with well maintained and pleasant garden areas which are used by residents, particularly during the warmer months. As a result of a recent inspection visit, the home has had some major repair work carried out on the drainage system. Evidence was seen of regular maintenance and servicing to the equipment in the home, including testing of emergency lighting, fire alarms and nurse call bells. Confirmation is still awaited that the recent recommendations of the Fire Safety officer to have a fire risk policy have yet to be provided. At the follow up meeting with the Regional Manager and Acting Manager the home was toured and found to be much cleaner, tidier and providing a more presentable and acceptable environment for the residents. Written confirmation has also been received that the cleaning and maintenance issues raised in the separate letter have been addressed. In addition to this, the rusty commodes have been disposed of, an order has been placed for new linings to the curtains, and the lack of carpet in one room is being addressed. The issue over leaking windows has also been addressed with a number of windows being repaired. A plan for refurbishment is also to be provided following a meeting with the Company. Confirmation is still awaited regarding the health and safety issues raised in the separate letter following the initial inspection on 10 June 2005. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 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 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 and 29 The current staffing arrangements mean that residents needs are not being met. The recruitment procedures for English staff are thorough and ensure that residents are provided with a degree of protection. Recruitment procedures for overseas staff must include a Criminal Record Bureau check to ensure protection of residents. EVIDENCE: Residents stated that they are not being given baths, one resident said they had not had a bath for three weeks despite asking staff. Comment received from a visiting relative stated that they had had to ask for their relative to have their hair washed. Similarly another relative commented that their relative had not had his hair washed for over 10 days, was “rarely shaved” when they visited and they too had to ask staff to undertake these basic care tasks. Residents spoken with also expressed concern that there are insufficient female staff on duty and they are not happy with having to have male staff undertake their personal care. One resident stated that they had not had breakfast on two occasions and had been missed for tea on another occasion. This was also raised as an issue by another relative who said that when they had spoken with their relative at the home at 8.00 p.m. one evening this resident had not been given any tea. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 20 Comment was also received from both residents and visitors that beds are very often not made until late in the afternoon. The majority of residents spoken with said that they usually have to wait a long time for staff to answer their call bells, one resident saying they had waited over 25 minutes and this was not unusual. A visiting relative stated that there was “no point in ringing the bell as no-one comes” and this was also raised by another resident spoken with. Another resident said that there are long delays between residents asking to go to the toilet and actually getting staff to take them. The concern that there was insufficient staff in the home was addressed in an official letter sent separately. Staff files for four recently recruited members of staff were examined and found to contain all the required information apart from evidence that a Criminal Records Disclosure check had been applied for in respect of the overseas staff. The home was advised accordingly. During this inspection, some residents and some visitors again raised the issue of the number of foreign staff employed at the home feeling that there are some communication difficulties. In addition, residents and relatives felt there was a lack of experience and understanding of the care needs of the elderly. One visitor commented that “the staff are very cheerful but they have a lack of awareness of the care needs of the elderly”. Observations of staff during this inspection confirmed that all were caring and sensitive to the needs of the residents. All residents were treated with dignity and respect. Staff also spoke of their commitment to ensuring the needs of the residents were met but acknowledged a need for a permanent manager to be in place. At the follow-up meeting with the Regional Manager and Acting Manager, confirmation was given of the action taken to date:Staff have had two staff meetings at which a large number of issues pertinent to both care tasks and staffing deployment were addressed. Minutes of these meetings were seen. As a result of this the shift patterns have been reviewed, an additional team meeting is now held in the afternoon to ensure all care and other tasks have been carried out and to identify what still needs to be done. Staff are also now being empowered to use and complete care documentation, including personal care charts for each individual resident. The Manager or Deputy Manager also now tours the home on a daily basis to ensure care and other tasks have been carried out to an good standard. Practical issues have also been addressed – for example the arrangements for storage, the purchase of a new shower chair and cleaning rotas. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 21 The Acting Manager confirmed that three new care staff from the local community have been employed, and the ratio of male and female carers are being addressed through the new shift patterns in place. This means that the personal preference to have a female member of staff to bath a female resident will be maintained. Although staff training was not assessed during this inspection, it was confirmed that a training analysis has now been carried out by an external auditor and a number of training courses for staff have been put in place – these include National Vocational Qualification training (both Level II and III), blended/distance learning in health and safety, and basic numerical and literacy skills development for staff that would benefit from this, and Food Hygiene and Nutrition for the chef. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 22 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) 31, 38.6 and 38.7 The management of the home does not provide leadership or scrutiny of care practices which means that the health, safety and welfare of residents is not protected EVIDENCE: There is currently no permanent manager in place in the home, a replacement for the previous manager being sought. At present, the home is managed by a Peripatetic Acting Manager who works alongside the Regional Manager. The accident book was examined and a number of accidents which link to care practices were noted. For example, one resident experienced a skin tear due to bed rail cushions (bumpers) not being put in place by staff, another resident having a skin tear caused whilst being moved. There does not appear to be any follow up actions or investigations by the manager at that time. This is a serious deficit which must be addressed to ensure the protection of the St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 23 residents in the home. Regulation 37 requires that the Commission for Social Care Inspection is notified of all accidents, injuries and incidents are report to the Commission for Social Care Inspection. This had not been consistently carried out by the previous manager. Risk assessments should be completed and reviewed monthly (or as necessary) and initial assessment information should be screened to identify if a risk assessment is required - for example, one assessment indicated “tends to fall” but no risk assessment had been completed. Maintenance and service certificates were seen, along with evidence of testing of equipment and alarms within the home. Confirmation is still required that the recommendations made by the Fire Safety officer in relation to a long-term risk assessment has been carried out. Residents appear stoical about the management changes to date. A number of relatives spoken with commented that they are concerned about the management of the home, with one relative stating that they feel the staff are not being given the support and direction needed. Following the initial inspection and the letter sent to the Regional Manager, the Acting Manager is now working at the home on a permanent basis until the new manager is in place. At the follow-up meeting with the Regional Manager and Acting Manager a number of management changes have been put in place and have already been outlined in this report. In addition to this, the Deputy Manager has been involved in disciplinary procedures and is gaining in confidence in the management role. It is intended that this will be further developed as a supervisory management course for her to attend has been identified. Although not assessed during this inspection, the Acting Manager confirmed that all staff have now received formal supervision and this will be ongoing. Importantly, a new manager is in the process of being recruited and is expected to be in post in the next few weeks. St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 2 2 x 2 2 2 2 STAFFING Standard No Score 27 1 28 2 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x x 1 x x x x x x 2 St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 25 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. 2. Standard 3 7 Regulation 14 15 Requirement The assessment of potential residents must be thorough and cover all areas The care plan must incorporate accurate information and provide clear instructions to staff over what and how the care is to be provided Healthcare needs must clearly be included in the care plan and maintained as needed. This includes weight records, nutrition, pressure care, and exercise Residents must feel confident their concerns, etc. will be listened to and addressed A refurbishment plan must be provided. Confirmation must be received over the long-term fire plan for the home Carpet must be fitted to the room identifed during the inspection. The cleanliness of the home must be maintained The number of staff must be reviewed to ensure the needs of the residents are being met Criminal Record Bureau disclosures must be obtained for F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Timescale for action 21.7.05 31.8.05 3. 8 13 31.8.05 4. 5. 16 19 22 23 21.7.05 31.7.05 6. 7. 8. 9. 24 26 27 29 16 23 18 19 31.7.05 21.7.05 31.7.05 21.7.05 Page 26 St Wilfrids Hall Nursing Home Version 1.30 10. 31 8 11. 38 13 12. 38 37 foreign staff prior to the commencement of their employment A suitably qualified and 31.8.05 experienced manager must be appointed to manage the home and to be registered with the csci Risk assessments must be 31.8.05 carried out and reviewed as appropriate for all residents and safe working practices The Commission for Social Care 21.7.05 Inspection must be informed of all accidents, incidents, injuries and occurrences in the home as required under Regulation 37. 13. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 28 Good Practice Recommendations The National Vocational Qualification Training for staff should continue St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection 2nd Floor, Unit 1 Tustin Court Port Way Preston PR2 2YQ 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 St Wilfrids Hall Nursing Home F57 F09 S6155 St Wilfrids V221554 070605 Stage 4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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