Inspection on 13/12/05 for St Wilfrid`s Hall Nursing Home

This inspection was carried out on 13th December 2005.

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

The inspector 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 10/06/05

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 Wilfrid`s Hall Nursing Home Foundry Lane Halton On Lune Lancaster Lancashire LA2 6LT Lead Inspector Mrs Joy Howson-Booth Announced Inspection 13th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Wilfrid`s Hall Nursing Home Address Foundry Lane Halton On Lune Lancaster Lancashire LA2 6LT 01524 811229 01524 811949 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) Latham Lodge Limited Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home must employ at all times a suitably experienced and qualified manager who is registered with the Commission for Social Care Inspection The home is registered for a maximum of 43 service users in the category OP (older persons). The registered manager must obtain National Vocational Qualification Level IV in Management by 31 December 2005. 10th June 2005 Date of last inspection 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 Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and carried out over one day by two inspectors. The purpose of this inspection was to assess the service against the key National Minimum Standards which remain outstanding for this inspection year and also reviewed actions taken following the requirements made in the previous inspection report. A number of residents were spoken with, along with visitors to the home. Both qualified and care staff on duty were also spoken with. As well as this, discussions took place with the relatively new manager of the home and the home’s regional manager. A number of care plans and other documentation were also examined. Feedback received from residents indicated that they felt very well looked after at the home and were well cared for by the staff. A large number of comment cards were received from both residents and relatives and generally the comments made were positive. Other comments made were discussed with the regional manager and manager and, where appropriate, action is to be taken. No comment cards were received from any healthcare professionals. What the service does well: What has improved since the last inspection? The manager of the home has only recently been appointed but has made some very positive changes, particularly in regards to staffing and training of staff to enable them to provide a high quality care service. Discussions with the regional manager confirmed that she is confident that once the new manager has settled into the home the service will develop further. St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 6 What they could do better: The care plans and healthcare records need to be much better as they are not clear and do not provide accurate information as to individual residents needs. Residents should be provided with a lockable facility in their room as the home currently asks residents if they would wish to have such a facility. It would be helpful for the home to know about residents social and employment history as this can provide a lot of information about likes and dislikes and how people like to spend their time and their interests. Consideration should be given to replacing the mini-bus as this is often breaking down and only a small number of residents can access. A refurbishment programme for the home needs to be formalised and submitted to the Commission, taking into account the comments made by residents and relatives during this inspection. Parts of the home are looking “tired” and do not provide as positive image as the company would perhaps wish. Some repairs were noted at this inspection and the regional manager is to ensure these are addressed. Staffing levels or deployment of staffing needs to be reviewed as, again, residents and relatives have raised issues over meeting needs. The plan to develop the home’s own bank of staff should be pursued as this would mean the use of agency staff can be limited and residents are cared for by people who know them. Staff training should continue, not only the more formal National Vocational Qualification (NVQ) training but also induction training and other training specific to individual roles. Update training on abuse awareness should be provided to all staff to ensure the protection of residents at the home. Training files need to be much more accurately maintained. Please contact the provider for advice of actions taken in response to this St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 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 the following standard(s): 3 There are good arrangements in place for the needs of residents to be assessed and met. This means that the people who are accommodated at the home can be confident their needs are ascertained and can be met. EVIDENCE: A requirement highlighted at the previous inspection required the home to ensure the assessment of potential residents is thorough and covers all areas. During this inspection, three care assessments were examined and are much more comprehensively being completed. Comment was made that when these are handwritten the writing needs to be clear so that all staff who may use this assessment can read and understand the assessment. One pre-admission form was not signed by the person who completed it, nor was it dated. St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 and 10 Care plans still do not contain sufficient information about individual residents. This means that staff have to rely on their knowledge and memory of the residents to provide their care. Systems are in place to ensure medication is safely administered to residents by people who are qualified to do so. Residents are treated with respect and dignity and their privacy is respected EVIDENCE: A requirement highlighted at the previous inspection required the home to incorporate accurate information into the care plan and provide clear instructions to staff over what and how the care is to be provided. In addition to this, healthcare needs were to be included in the care plan and maintained as needed. During this inspection, a number of care plans were examined and the following noted : St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 11 Care plans are beginning to contain information transferred from the preadmission assessment forms but not all files do so. Evidence was found that a full medical history was not always documented. In addition risk assessments, consent forms and dietary needs amongst others are not contained in the care plans Care plans contain some information which is historical and it is unclear if these are still pertinent – for example, wound dressings and risk assessment for bed rails done on 24.3.05 but no further assessment or review carried out and it is not clearly stated in the care plan whether bed rails are to be used or not. This and other similar matters have been raised previously For the majority of care plans examined, it was evidenced that healthcare needs are being met. Evidence on files for nursing interventions - BP monitoring, blood monitoring, pressure care, catheter care, etc. Also monitoring checks carried out every quarter hour for some residents – confirmed by staff. Nutritional and fluid intake monitoring also taking place, along with weight monitoring and this was also confirmed through discussions with staff Also evidence of GP, chiropodist, dietician, dentist, involvement, etc. on care files. It was noted that, some files do not evidence that any follow up action following particular circumstances surrounding an individual’s care and treatment has taken place. The Regional Manager confirmed that the company are putting in place new and revised care plan folders for each of the residents. It was agreed that the home would have all these in place by 20 February 2006. The medication room was secure, clean and tidy. Trolleys were seen to be clean and tidy. The Medication Administration Record sheets (MARs) generally accurately maintained, although a couple of minor discrepancies were seen The controlled drugs records and stocks were accurate. A disposal form now used for CD’s along with destruction kits. The qualified nurse on duty confirmed that only qualified staff administer medication to residents. Residents and relatives all confirmed (via comment cards) that they feel they are treated with privacy and dignity by the staff at the home. St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 12 Observations during this inspection confirmed this. Care plans have a form which is to be signed asking if the resident would like a lockable facility – this facility should be provided to all residents unless their care plan indicates otherwise. St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 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 the following standard(s): 12, 13 and 14 Overall the home has satisfactory outcomes in providing for residents social and daily activities needs. This means that in the main residents are enabled to maintain contact with the wider community and to participate in daily activities if they wish to. Resident’s benefit from seeing their families when they want. Those residents who are able to do so exercise choice and control over their lives. EVIDENCE: Discussion with the Occupational Therapy (OT) staff confirmed they are employed to work as designated activities staff for 20 and 6 hours (respectively) during the week For those residents who are able to they follow their own lifestyles. Other residents are dependent on staff and their relatives for social stimulation and this is where the importance of social histories, interests, etc., comes into its own. Most files have a biography and interests sheet included, although these are not always completed. The importance of knowing about residents cannot be stressed enough so that individual residents feel their care plan is based on St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 14 holistic knowledge, not only of their medical needs but also about them as a person, with their own likes, dislikes, preferences, interests, etc. Discussions with OT’s during the inspection confirmed they are trying to take a more individual approach to what they offer and a big part of this would be to find out social history, likes, dislikes, interests, etc. Social and leisure activities are important to ensure residents do not become depressed through lack of stimulation. All but two of the residents comment cards received stated that they felt the home provides suitable activities. The home has an ‘Events Committee’ which has put on Halloween and Bonfire Party and, more recently, a family day which was enjoyed by everyone. Staff have invited relatives and family members to be involved in this committee. Residents commented that often the trips out are just rides in the mini bus and they never get a chance to get out and get some fresh air. All those who took part enjoyed the outing to Leighton Moss in the summer. A Church service was taking place during the inspection Concerns expressed that some people sleep all day due to lack of stimulation and then they are awake ringing call bells at night Comment was made that the mini bus belonging to the home is poor – it is often breaking down so people don’t get out as often as they would like. As a result, staff have to hire a bus which costs quite a lot of money. It was advised that the manager could discuss with residents and their relatives the idea of using their own money to contribute towards 1 to 1 outings. Where money is an issue, the management can discuss with and appropriate person. Another suggestion was the possibility of having a monthly or quarterly newsletter so that residents and relatives are kept informed and can feel more included. Residents spoken with were all aware they had a care file about them. Some disclaimers were seen on file for residents who do not wish to be involved in their care planning. Residents confirmed that their family, relatives and friends can come at any time. Two relatives were met during the inspection who confirmed they are always made welcome. Comment cards received from relatives all commented they are made to feel welcome at the home and can visit their relatives in private, although one comment card indicated they did not know this could happen. St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 15 Access to local community restricted by the home’s minibus and the cost of transport. It is noted that a number of the residents are restricted by their frailty and dependence on others One resident commented about the front door being kept locked. This was discussed with the regional manager and manager with an official letter being sent out. The front door was unlocked during the inspection. Most residents spoken with and those who sent in comment cards all confirmed they are very content in the care they receive and that they are free to make choices. St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The arrangements for dealing with complaints are good. Residents can speak up and feel that they are listened to. Although there are procedures regarding abuse in place, induction and other training provided record do not evidence this. This means the manager of the home cannot be confident staff know the systems and that residents are protected from abuse. EVIDENCE: Residents spoken with said that staff listen to their concerns and try to sort them out. Residents meetings have been held in September, October and November. The next planned residents meeting is on 20 January 2006. 13 comment cards were received from relatives and 7 of these indicated that they were not aware of the home’s complaints procedure. The remaining 6 were aware, with three having made “minor” or “small” complaints. One comment card indicated that “only ever had to make one small complaint which was swiftly and satisfactorily dealt with”. Since the last inspection, there have been no complaints made to the Commission for Social Care Inspection about the service provided at St Wilfred’s. However, just prior to this inspection commencing, and during the St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 17 inspection, two separate anonymous complaints were made to the Commission, which have been passed to the Regional Manager to investigate. Discussions with staff on duty confirmed they were aware of the forms of abuse and what action they should taken should any incident of abuse be suspected. The home has abuse policies and procedures in place and these are known and accessible to staff. In a later standard, the induction programme for some members of staff could not be found. This needs to be addressed as induction forms an ideal training opportunity for the abuse policies and procedures (including whistleblowing) to be made known to staff. In addition to this, training files should evidence that staff have been provided with abuse awareness training – some training files were not available at the time of this inspection. St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Improvements to the cleanliness of the home have taken place which means the residents are live in a more pleasant environment. The standard of décor within this home remains adequate but there is little evidence of planned refurbishment taking place which is needed to ensure the residents live in a safe, comfortable and well maintained environment. EVIDENCE: A requirement highlighted at the previous inspection required the company to provide the Commission with a refurbishment programme for the home. This has not been provided. Also outstanding is the need to confirm the long-term fire plan for the home. The Regional Manager confirmed these are to be provided. Generally the home is much cleaner and tidier and no concerns were raised during this inspection. Not all rooms were seen or inspected, however. St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 19 Some repairs/observations were noted during this inspection and the Regional Manager and Manager informed of these. Staff spoken with said the downstairs toilet is very difficult to access given the number of residents who use wheelchairs and need staff support. In addition, residents felt there were insufficient toilets in the home as there were often queues to use the toilets. These concerns were discussed with the Regional Manager and Manager with advice that a review of the current toilet facilities be undertaken and an action plan provided to address the concerns raised. One comment card from a relative was discussed with the Regional Manager and Manager who confirmed they had spoken with this relative and addressed satisfactorily. Cleaners spoken with felt they were short staffed and an action plan is requested as to how the home are to address this. There are plans in place to erect a Conservatory – the Regional Manager is to submit plans to the Commission once planning permission has been achieved. St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Staff are properly vetted before taking up employment meaning that only people who are suitable work at the home. However poor recorded training and deployment of staff means that residents’ needs are not always appropriately met. EVIDENCE: A requirement highlighted at the previous inspection required the home to review the number of staff on duty in the home to ensure residents needs are being met. Through discussion, staff are still clearly saying that another member of staff is needed, particularly at busy times of the day. Concern was also raised over staffing at the weekend as the help provided by the Occupational Therapist is not available and staff commented that the care is more rushed. This was raised by both staff on duty and staff who have commented separately. Staff indicated that, apart from four residents, the remaining people accommodated at the home are dependent on two staff for their care. Discussions with residents also echoed the comments by staff in that they are saying that they often have to wait a long time to be taken to the toilet or for staff to answer their nurse call bells. St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 21 Observations made during this inspection a number of occasions when staff were heard to say to residents – can you just give me a couple of minutes and I’ll be back. Staffing issues were discussed with the Regional Manager and Manager who are to do their own assessment, although the Regional Manager confirmed that the staffing levels have risen since the last inspection. Comment made by one resident “staff are leaving as quick as the leaves are falling from the trees. This leaves me feeling sad that the people we know are no longer here and new staff have to get to know us all over again.” This comment was passed onto the Regional Manager and Manager who are aware of the recent staff changes and are hoping to reduce the staff turnover now the new Manager is in post and management of the home appears more stable. Special comment made by three different residents about one carer who is especially good and kind. This carer’s name was passed onto the Regional Manager and Manager. Several residents commented that the agency staff are “hard to understand” and “they don’t know or understand us”. This was discussed with the Regional Manager and Manager who confirmed that they are compiling their own bank staff so that the use of agency staff can decrease. Advice was also provided that they need to have confirmation that any agency staff have had the satisfactory clearances. The Regional Manager confirmed that this has been received. Comment cards received in relation to staffing noted : All residents who completed said that staff treat them well and staff were kind. Two of the thirteen comment cards received from relatives felt there was not always sufficient staff on duty. One comment card indicated they felt they were unable to make a judgement over this. Comment cards from relatives indicated they are satisfied with the overall care provided with comments including “I am very satisfied with the care that my relative receives” and “very friendly staff who are always easy to approach”. A requirement highlighted at the previous inspection required the home to ensure all overseas staff have satisfactory Criminal Record Bureau (CRB) disclosure forms. Apart from one member of staff, all staff, including overseas staff, have CRB disclosures on file. Advice was provided over one CRB form. In relation to National Vocational Qualification training in the home, the Regional Manager confirmed that all but 2 staff are now on the NVQ Level II St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 22 training programme. 1 person has NVQ Level II and 3 people have NVQ Level III. Staff training files were examined but did not clearly evidence training. For example, for the three files examined – One fairly new member of staff had evidence of training certificates. However, the home’s induction was completed but not dated Moving and handling training for another member of staff – it was not clear whether the signature was that of the trainer or of the member of staff. In the same example, it was not clear whether all the different aspects had been shown and understood. This same member of staff had no induction file but evidenced that they had done fire safety training and abuse training. In addition, there was a confirmation letter that they had been accepted for the NVQ II training. The third member of staff had no training file in evidence. The Regional Manager and Manager were informed of the above and advised that all staff should have their own individual training file which can evidence what training they have undertaken, along with copies of certificates. In addition, a training matrix should be set up to aid planning. St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The arrangements to protect the residents’ money and property are good. Experienced and qualified management staff run the home. Residents live in a well managed home. The management of the home ensure the health and safety of the residents who live there. EVIDENCE: A requirement highlighted at the previous inspection required the home to appoint a suitably qualified and experienced manager to manage the home. The company has recently appointed such a person and it is expected that a decision over the registration of this person will be taken soon. The new Manager is beginning to exercise leadership and scrutiny of care practices St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 24 which is reflected in the comments made by residents and relatives. In addition, the new manager is willing and eager to address the issues raised in the feedback given following the inspection. The home has a formal quality monitoring system in place and includes monthly visits by the Regional Manager as part of her Responsible Individual responsibilities. The Commission receives a monthly report as required. Staff confirmed they are beginning quality circles to look at improving the care practices and the home generally. Representatives from all areas of staff (qualified nurses, carers, ancillary and other staff) are involved. A number of residents who completed comment cards indicated that they would like to be more involve in decision making within the home. In relation to financial matters, personal allowance sheets and finances held for residents were examined and found to be accurately maintained Invoices were seen and advice given that perhaps these need an invoice number to avoid confusion It was seen that financial records are checked by the Regional Administrator as part of the (monthly) Regulation 26 visits Advice was given to the office administrator over receipt of valuables held for residents Advice was also given over ensuring private healthcare arrangements are discussed and agreed with residents (or their families) before these take place. The pre-inspection questionnaire confirmed that there have been no changes to the premises. Confirmation was also provided that all the maintenance and health and safety checks are carried out, with visits from Fire, Environmental Health and associated trades people concerned with maintenance of equipment and facilities. It was noted that staff files do not evidence that they have had the home’s induction. In addition, it is unclear from the records what mandatory training has been undertaken by which staff. The Regional Manager and/or Manager have been asked to confirm this in writing, along with a plan of action for any staff who have not completed the mandatory training. It was confirmed that the Company’s policies and procedures remain in place and are reviewed on a yearly basis. These are located in the main downstairs office and are available to staff. St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 25 Risk assessments are undertaken by the manager. Risk assessments were seen on resident’s files and staff on duty were aware of their existence and content. The Regional Manager confirmed that risk assessments for safe working practices and for the home have been carried out, including a fire risk assessment for the home. The accident book was not examined on this occasion but a letter has been forwarded to the Regional Manager providing advice and guidance over the Regulation 37 notices sent to the Commission by the home. St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 x X 2 St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 27 Are there any outstanding requirements from the last inspection? yes 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 Regulation 15 Requirement The current care plans must be reviewed and provide current information over the care needs of the residents at the home (Previous timescale of 31/09/05 not met) Healthcare records must be consistently maintained to reflect the healthcare input provided to residents Those staff who have not already accessed mandatory training, abuse awareness training or other training appropriate to their roles should be provided with this A refurbishment plan must be provided. Confirmation must also be provided over the longterm fire plan for the home. An action plan which addresses the comments made within this inspection report relating to the downstairs toilet must be provided The staffing numbers and/or deployment within the home must be reviewed to ensure that residents needs are met DS0000006155.V258141.R01.S.doc Timescale for action 20/02/06 2 OP8 13 20/02/06 3 OP18 12 31/03/06 4 OP19 23 31/01/06 5 OP27 18 31/01/06 St Wilfrid`s Hall Nursing Home Version 5.0 Page 28 6 OP30 18 All staff must have their own training file which indicates the training undertaken and evidences this with copies of certificates gained Repairs discussed at the inspection must be addressed 31/01/06 7 OP19 23 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 Refer to Standard OP38 Good Practice Recommendations A lockable facility for each resident should be provided as part of their furnishings and residents should not have to indicate whether or not they wish to have this facility. If a resident does not wish a lockable facility then this should be noted on their care plan. The company should consider replacing the home’s minibus with one that can accommodate a larger number of wheelchairs Activities should be linked to individual wishes, likes, interests and preferences Relatives and visitors should be reminded of the home’s complaints procedure location Discussions could take place with residents and their relatives over funding for one to one outings A training matrix may be helpful in identifying training for staff, also update training Invoices issued to residents or relatives should be numbered Where private healthcare arrangements are made (for example a private chiropodist) the manager should ensure that a consent form or agreement is gained The National Vocational Qualification training should continue to be undertaken by staff at the home 2 3 4 3 4 5 6 7 OP13 OP12 OP16 OP13 OP30 OP35 OP35 OP30 St Wilfrid`s Hall Nursing Home DS0000006155.V258141.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection North Lancashire Area Office 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. 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