Inspection on 09/08/07 for St Wilfrid`s Hall Nursing Home

This inspection was carried out on 9th August 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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

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

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 Unannounced Inspection 9th August 2007 09:30 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.V341714.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 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 stwildfrids@caringhomes.org latham@caringhomes.org Latham Lodge Limited 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) Mrs Jeanette Elizabeth Bacon Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (1) of places St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 41 service users. 40 service users in the category OP (older persons over 65) 1 named service user over 60 years of age in the category of PD (physical disability) 19th June 2006 Date of last inspection Brief Description of the Service: St Wilfred’s is a care home situated in the small village of Halton-on-Lune, some 4 miles North of Lancaster. The home has many historic features including fireplaces and stained glass windows; it is set in its own extensive grounds. The home is a three-storey building, with resident accommodation over the ground and first floors. There are three lounges, one is used as a smoking room and there is a separate dining room. There are basically adequate toilets and bathrooms at the home. The general fabric of the home is satisfactory. The home has its own transport that is used to take residents out. At the time of this visit, (19/6/06) the information given to the Commission showed that the fees for care at the home were £386.00 to £520.00 per week, dependent on the room chosen, with added expenses for hairdressing, chiropody and newspapers. Latham Lodge Ltd owns the home and the regional manager is Mrs Sheila Head. The home has a manager who is registered with the Commission for Social Care Inspection. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first site visit and was unannounced so the registered providers, registered manager, staff and residents were not aware of the visit. The inspector for the service carried out the site visit. The site visit forms part of the overall inspection for the home which makes sure people are being cared for properly and to make sure the home is a safe place for people to live in. As well as the site visit, judgements have been made about the service based on information supplied by the registered manager. Comment cards were made available to residents, their relatives and GP surgeries. Responses were received from both residents and their relatives who were very satisfied with the service provided. Responses received from GP’s generally expressed satisfaction with the service provided, although an individual comment made by one GP was discussed with the registered manager. The site visit took place over one day and included taking time to sit and speak with residents, spending time observing staff on duty performing the day-today care tasks, speaking with staff and speaking with the registered manager. In addition, a visiting healthcare professional and other visitor were spoken with and both gave a positive view of the care provided. The home’s registered manager was available during the inspection to answer questions and provide additional information. The inspector looked around parts of the home, including communal rooms, a number of personal rooms, bathrooms and toilets to see first hand if the home was a comfortable, clean and safe for people to live in. Every year the registered persons are asked to provide us with written information about the quality of the service they provide and to make an assessment of the quality of their service. This information, in part, has been used to focus our inspection activity and is included in this report. The site visit was enjoyable with everyone welcoming, friendly and cooperative during the visit. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 6 What the service does well: St Wilfred’s is situated in the small village of Halton-on-Lune and prior to becoming a care home was a large private residence. It is situated in its own very extensive grounds, and 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. Generally the comments from people living at St Wilfred’s, and their relatives, were very complimentary about the care provided by the manager and staff. Individual comments from both residents and their relatives include - “the staff are very friendly and welcoming. They are willing to listen to your concerns if they should arise”; “the care home provides the care needed by relative. They make sure she is clean and well fed. They also make sure her room is clean and tidy. They also ensure medical needs are met if needed. They contact us the family when needed – i.e. illness, etc”; “my relative’s health has improved since been in home” ; “we are always kept up to date with important issues – “doctors/hospital visits they will phone, or tell me in person whilst I am on a visit” ; “they take care to talk, a kind word to the residents goes a long way, there days can be very long sitting due to incapacities. This is their home not a hotel and they need kindness and a smile and time, which is given where possible from all staff, in their busy schedule”; “I am contacted by the home with details of any care to be provided following which I consider proposals and then respond appropriately” and “I can always call to ask about (my relative’s) condition. If there is a problem they call me.” All registered care homes are expected to keep a written record for every resident, which describes their needs and how the care that is given meets these needs. These records are called care plans. A number of these were sampled and showed that a satisfactory system is in place. There was equality of care in the home in that all residents were supported by the activities co-ordinator either to take part in activities in the home, or by being given attention to enjoy an activity. Activities within the home continue to be developed so that residents are provided with stimulating and interesting things to do. Events in the home like Valentine’s Day, Easter or the Summer Garden Fete are inclusive of both residents and their relatives and form an important opportunity to socialise. The home offers a flexible approach to mealtimes with two sittings. The first sitting ensures that residents who need support are given this and those who are more independent can eat at a slightly later time. Observations at lunchtime indicated that people are supported at mealtimes in a sensitive and caring way and no one was rushed or hurried to finish. Staff mandatory and National Vocational Qualification training programmes continue and make sure that the residents are looked after by competent staff. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 7 The staff interaction with residents, their relatives and visiting professionals was very good, confirming that dignity and respect are an important part of the care that is given at the home. What has improved since the last inspection? What they could do better: The home needs to ensure that a record of food provided to the residents is made, including food provided to people on any special diets. This means that monitoring can then be done on the quality and quantity of the food given to the residents. The people who own the home need to continue with the refurbishment programme so that all parts of the home, including the rooms used by individual residents, are to a good standard. An ongoing issue regarding water leaking in through windows remains unresolved and must be addressed as a matter of priority. A number of minor repairs were discussed with the registered manager who is to ensure these are addressed with the help of the new site maintenance officer. The home is currently working with the Fire Safety Department to ensure the safety of residents. The registered manager confirmed that the registered provider is dealing with this issue and the commission requires notification when the situation has been resolved. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 8 On arrival at the home, the front door was unlocked and open - this does not provide vulnerable people with safety and security. The home should look at a system so that residents (who are able to do so) can enter and leave the home freely but protects them by preventing strangers having open access to their home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 9 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.V341714.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3, 4 and 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The system for assessment of prospective people in the home is very comprehensive and enables a judgement to be made by both parties as to whether the home is suitable. EVIDENCE: Information provided by the home and discussions with the registered manager confirmed that all new residents are provided with information in the form of a welcome pack. This information outlines the homes facilities and services and also the complaints procedure. Residents spoken with were able to confirm that they had received information on arrival. The home is also looking to provide a promotional DVD to enable potential residents to view a day in the life of the care home. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 11 As some people were not aware of all the information in the Service User Guide and Welcome Pack, it may be useful for the key worker to go through the welcome pack again once the resident has “settled in”. Comments from both residents and relatives all indicated they had received enough information about the home to decide if it was the right place for them. Individual comments included - “matron and staff very helpful”. Information provided by the home confirmed that contracts are provided to all residents. This was confirmed by residents/relatives in survey forms completed. Assessments for three recently admitted residents were examined and found to be comprehensive and includes personal, social and religious information and individual wishes of the resident being assessed. The registered manager confirmed that any specific cultural or other individual need would be found out at this point for inclusion in the care plan. Information provided by the home indicates that there is a need for more trained assessors, along with time and transport to do assessments. Staff confirmed that they get to know about new resident’s needs via handovers given by matron and other staff. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 and 11 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents health and social care needs are met and people are treated with dignity and respect at this home. EVIDENCE: Information provided by the homes states a person centred approach is used to meet individual needs, and the home promotes and encourages the residents right to choose and control their daily lives. Each resident has their own care plan, a selection of which were examined, and found to contain a deal of information which outlines both care and healthcare needs and how the staff at the home are to meet these. There was evidence of a range of nursing interventions and monitoring, along with involvement of the resident concerned. Monthly reviews are taking place to ensure the information over needs remains up to date St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 13 Staff spoken with confirmed that they are made aware of diversity and equality issues relating to individual residents, usually by the qualified nurse or senior carer. Feedback from residents indicate that people are satisfied with the level of care provided – individual comments included – I have very good care”. Comment cards from most relatives indicated that they felt their relatives received the care and support they needed and comments included - my relative “is usually content and nursing staff take good care”; “she is very happy there!” and “they take good care of her”. Some concerns were raised by relatives about attention to personal care for residents - one relative commented that since the home “introduced regular bathing/washing my relative has been better dressed and cleaned and some better attention to mouth care has been given – that had been neglected”. Another relative commented “at a basic level the general care has improved a bit over the last few months – since more nurses were employed and junior carers have a bit more supervision”. This was discussed with the registered manager who is to ensure these improvements are maintained. Care plans evidenced that residents are provided with healthcare input and monitoring. Input from other healthcare professionals was also seen in individual care plans. Staff were asked about the individual care needs of a selection of residents, and were able to describe both care and health needs and how these are being met All residents responded positively that they receive the healthcare they feel they need - one resident commented – “I’ve seen lots of doctors”. A relative commented “my relative’s health has improved since been in the home”. During the inspection visit, a visiting professional was spoken with who confirmed that she is very happy with the proactive work done by the staff at the home. The professional also commented that the senior carer was “excellent” and provided a good lead to other staff. GP’s who returned comment cards generally indicated that the home usually met the care needs of individual residents. One GP comment card gave positive feedback and stated the home offered ““a pretty fair service on the whole. Very caring”. However, another GP comment was discussed with the registered manager who provided further information over the comments made and is intending to speak with the GP to address the issue raised. Medical Administration Records (MARs) sheets and medication stocks were examined for those residents case tracked and found to be accurately maintained. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 14 Residents spoken with (who were able to say) confirmed that they are given their medications properly and on time. Examination of care plans evidenced that one consent form for self medication was completed “N/A” – advice given that the assessment should take place and the form completed to evidence that the individual’s right to manage their own medication had been considered. Advice was also given that the medication assessment and consent form may need to be reviewed so that areas of understanding/GP involvement could be included. The form needs to include understanding and GP involvement to address areas where there are concerns over potential misuse or risk. The majority of comment cards from residents indicated that staff listen and act on what they say. Two commented “always” and “most times”, although one commented “but can be slow – may take till the next day.” Residents spoken with all confirmed that the staff treated them with dignity and respect and their privacy is maintained. Staff spoken with were able to speak about how they ensure people are treated with dignity and respect and how individual residents’ privacy maintained Relatives confirmed that the home keeps them informed and kept up to date with important issues affecting their relative/family member. One comment card included – “I can always call to ask about her condition. If there is a problem they call me”. The 3 GP comment cards all confirmed that the home usually respects individuals’ privacy and dignity. The home has policies and procedures for people who are dying and when death occurs. A number of qualified staff at the home have been trained in Liverpool Care Pathways (which ensures that an intensive multi-disciplinary care input is provided (including the resident, their relatives and their own GP) when death is close so that unnecessary interventions are stopped and only the necessary (e.g. pain relief) interventions take place. This ensures that the resident is provided with their chosen level of input, according to their personal and religious preferences, which is dignified and pain free. Relatives are welcomed and supported by the manager and staff during these circumstances and are able to spend as much time as they wish with their relative. Evidence of this system was seen in one care plan and demonstrates that this is a proactive approach to providing end of life care, with dignity and respect and ensures that the resident and their families are supported in the way they wish. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 15 The registered manager confirmed that the home are now looking to purchase their own syringe driver which will be kept for future use in the home. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are provided with a reasonably good quality of life although further developments are still required to activities and improvements to mealtimes. EVIDENCE: Information provided by the home’s registered manager confirms that the home “actively promotes lifestyle choice and participation” with “routines in the home is flexible to meet the needs of the residents”. Information over this is gained in a variety of ways – bibliography, lifestyle information, questionnaires, care plans, residents meetings. The home has two activities co-ordinators who promote and encourage service users to make a choice of activities that they wish to do – one of the activities co-ordinators has just gained a certificate in activities for older people award. In addition, there is an “events committee and a gardening committee” both of which have been set up in the last 12 months. The gardening committee is currently seeking ideas and plans for the development of the garden area St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 17 following an award of £9,000.00 to be used to improve the environment for the residents. Examination of care plans indicated that all residents are asked about their social and family history and hobbies and things of interest. However, comments from residents varied over the activities provided – most saying that there were only “sometimes” activities suitable for them to take part in. Where residents do not wish to take part in activities, this is noted and respected. Information provided by the home indicates that the home has a programme of activities, including a church service every month (when the community is invited), visiting clergy once a week, its own service every two weeks where the residents can choose their favourite hymns and readings. Activities records evidenced that a range of activities are offered and enjoyed, both group work and individual work. Activities are clearly enjoyed when there is an “occasion” – for example, Valentine’s Day or Summer Garden Party. At the time of the site visit, birthday celebrations, along with birthday cake was in evidence for one resident. Some activities offered to residents seemed to be somewhat repetitious, but it is recognised that activities are still being developed. Discussions with residents confirmed that activities have improved but there is still a need to provide the opportunity for people to get out. A number of people feel they would like to go out on outings, “to the shops” or “just for a ride”. The home should ensure that every effort is made for people to have the opportunity to go out. The registered manager was asked about the home’s mini-bus and confirmed that earlier in the year the mini-bus was off the road but currently they are waiting for the recently appointed Site Maintenance Officer to complete his mini-bus driver training. Once this has been done, outings will then be planned. Feedback from relatives also raised concerns about the lack of activities and stimulation in the home. Individual comments included - “sitting in TV lounge watching TV is all that people do” and the home could “try to jolly things up – it’s terribly depressing sometimes there”. Although comment was also made that staff do try and take time to talk to the residents but are often busy. Relatives also indicated that the home “usually” helps people to live the life they choose “up to a point” but choices are limited. This was discussed with the registered manager who felt that activities continue to be a developing area for the two new activities co-ordinators. However, she also felt that sometimes relatives do not visit when activities are being enjoyed and intends to reinstate a newsletter so that relatives can be kept up to date of the activities residents have taken part in. No issues were raised over maintaining contact – most relatives confirmed that residents are encouraged and supported to do this. Comments included “I can St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 18 always call to ask about her condition. If there is a problem, they call me” and “Doctors/Hospital visits they will phone or tell me in person whilst I am on a visit” Information provided by the home confirmed that residents are supported to take part in postal voting, if wanted. It has already been noted that residents are able to manage their own finances – only a handful of people are able to do this at present, residents spoken with confirmed that they generally leave finances for their relatives to deal with. From visiting residents in their own rooms, they are clearly able to bring in items of furniture to make their rooms homely and comfortable. Residents comment cards raised some concerns over food provided - “I would like more fresh fruit and fresh vegetables. Breakfast is my favourite meal. I do not like the fish and meat.” And “meals can be ‘poor’ especially teatime”. Relatives commented that they feel the meals could be improved. Individual comments included – “the meals are variable”. These comments were discussed with the registered manager who agreed that over recent weeks there have been problems with the meals. However, a new chef has recently been appointed and the registered manager feels the quality and quantity of food is improving. Information provided by the home indicate that “during residents meetings the menu choices are discussed and the residents can choose their favourite dishes to be placed on the menus.” Residents who wish to eat in their own rooms are enabled to do so. The home has purchased a menu holder so that residents can be informed of what the meal choices are. Residents spoken with at the site visit did not raise any issues over the food provided. A meal was taken with the residents, which was satisfactory. People needing assistance were given this in a caring way and no one appeared rushed or hurried to finish their meal. Observations made during the lunch were passed onto the registered manager. Relatives raised concerns about the level of support available for people who need assistance and the general empathy needed to encourage and ensure residents are supported to eat a balanced diet. This is something that was highlighted in a recent complaint and was discussed with the registered manager. The home are trying to address this and have introduced a “protected mealtimes” system. This means that relatives are asked not to visit at mealtimes so residents can be supported without distractions and with their privacy and dignity respected, and staff are free to do this. Should a relative wish to visit at mealtimes then arrangements are made for them to eat with their relative separately. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 19 There were no records of meals served and the registered manager was reminded of the Care Homes Regulations regarding this. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 20 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home’s policies, procedures and practice make sure that residents are supported and protected. EVIDENCE: Information provided by the home indicates that they have received 5 complaints in the last 12 months. The commission has not received any complaints in respect of this home. The complaints records were examined and, after discussion with the registered manager, it appears that two of the upheld complaints were about leaking windows and these remain outstanding, as the company have not addressed the problem. One complaint is still ongoing. The complaints procedure remains the same and as well as being on display, it is also included in the home’s Statement of Purpose and Service User Guide. Information from the home also notes that they are asking the local blind association to translate into Braille the complaints procedure for the benefit of residents who are visually impaired. Discussions with residents confirmed that if there was any problem or concern they would speak with either Jeanette (registered manager) or Gladys (deputy manager). Comment cards from residents also confirmed this. Individual comments include – “talk to the ‘top St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 21 people’ – senior nurses”; “matron or Gladys”; “if I wanted to complaint I would ask Gladys, matron or Pam”. Relatives who completed comment cards all indicated that they knew about the home’s complaints procedure and the home “always” responds appropriately if they raised any concerns. One relative said they were very impressed by the action taken when they raised a serious complaint. GP comment cards indicated that the home generally responds appropriately if any concerns are raised. The registered manager confirmed that all staff are trained in all areas of adult protection issues and that there is a whistle blowing procedure in place. 1 safeguarding adult referral has been made in the last 12 months. As a company, there are robust procedures in place for dealing with any issues around abuse and there is also a structure so that staff can raise issues with other senior managers if any concerns centred around the direct management of the home. Discussions with two staff confirmed that training has been given in this area and staff are aware of what to do and who to contact if any safeguarding adults issues is raised. On entering the home the front door was unlocked – the registered manager was advised of this and the need to ensure people do not have open access to the home. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Generally the communal areas are safe and comfortable although some individual rooms require refurbishment. EVIDENCE: Information provided by the home noted that there has been a new entrance hall carpet, 10 rooms have been redecorated and refurbished and 11 rooms and 1 stairway have been recarpeted/refloored. A new doorbell for visitors and spotlights in the entrance above seating to enable the residents to see more clearly. In addition, a range of new equipment has been purchased. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 23 The registered manager confirmed that the refurbishment of the home is ongoing, with a new carpet chosen for the blue lounge and new flooring requested for the dining room. The home has recently appointed a new site maintenance officer and the registered manager is pleased with the work done to date. A couple of bedrooms have been redecorated and she is anticipating further renovation work will be carried out once his induction period has been completed. A tour of the home took place during the site visit and, whilst the home was clean and tidy, a number of residents own rooms and ensuites are now looking the worse for wear and need refurbishment. Individual observations were provided to the registered manager. In addition, both the upstairs and downstairs bathrooms would benefit and provide a more positive image if they were modernised. From discussions, it was suggested that the downstairs toilet layout be reviewed as currently people who need assistance or use wheelchairs have difficulty accessing this facility. Residents spoken with and those who completed comment cards were generally satisfied with the environment, although one person commented “the home is a bit grubby”. The registered manager confirmed that the work needed in the laundry room was completed straight away after the last inspection visit. Two complaints were made over leaking windows and, according to the registered manager, remain outstanding. The required work to address this problem needs to be done as a priority. Information provided by the home confirms that there are Control of Substances Hazardous to Health (COSHH) information procedures in place and also a policy for preventing infection and managing infection control, using the Department of Health’s guide “essential steps” to assess current infection control management. 99 of staff have received training on the prevention of infection and management of infection control. Staff carry small bottles of antibacterial hand gel for use; there were also safety dispensers of this throughout the home. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 28 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The level and calibre of staff is generally good. Residents are safeguarded as their care is provided by a staff team who are vetted, qualified and competent. EVIDENCE: Discussion with the registered manager over staffing of the home confirmed that rather than having a set rota, she has been allocated a number of hours so that she can use and deploy staff as residents needs dictate. Information provided by the home indicates that they have their own bank staff on hand in case of emergency sickness. Discussions and feedback from residents confirmed that staff are usually available when they need them – “I just ring my bell” and staff listen and act on what they say. Relatives indicated that the increase in nursing staff has been welcomed – “they have improved the general level of nursing care – more nurses on duty and this is a good thing”. Staff spoken with confirmed that there is usually good communication between staff members, with handovers at the start of each shift, communication books, St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 25 care plans/daily diary notes and qualified staff on hand for further advice or clarification. One relative raised concerns about staffing levels in the evening which was discussed with the registered manager, who confirmed that an additional senior carer is to be employed for the evening shift and she also intends to monitor the evening care provided. Other relatives comments about staff included – “I cannot praise the staff too highly” ; “new staff have training and appears all staff regularly have updates”; the senior nurses are always friendly and willing to discuss things”; “there are one or two v. good caring carers and that makes an enormous difference to the attention people get”. Relatives indicated that there may be a need for additional training for some staff – “some staff are good and caring and skilled – when they are on duty you know things will be ok. But at other times staff are on duty who are not ok.” “Sometimes it is obvious staff need some more skills training and a bit more compassion” and “often feel carers just don’t get the ‘empathy’ skills needed. This was discussed with the registered manager who intends to address this with monitoring and input from the qualified staff and further training. Information provided by the home states that of the 15 care staff employed 10 have qualifications National Vocational Qualifications (NVQ) Level II or above. This means that 66 of staff are trained to above the minimum level. 7 staff are currently enrolled on NVQ Level II in care. The registered manager confirmed that all the required checks are carried out on staff prior to commencement of their employment and all staff have a Criminal Record Bureau Disclosure check, which means they are safe to work with vulnerable people. Two staff files were examined and confirmed this. Discussions with care staff confirmed that there is a good training programme in place, with induction and other training being covered, along with an assessment of competency. The home has its own in-house training co-ordinator who has external accreditation. Information provided confirms that staff are undertaking a range of internal and external training. 1 member of staff is also has professional membership of the “back exchange and back care”. As mentioned earlier, there is a new chef in post and support and guidance are being offered by the registered manager. Training for auxiliary staff has included National Vocational Qualification (NVQ) II in Housekeeping, NVQ I and II in catering. A member of administration staff has NVQ III in Administration. In addition, qualified staff are updating their knowledge by attending external courses. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 26 The senior carer has submitted and has had an article published on wound management in the Convatec Clarity magazine which promote excellence in clinical practice. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 27 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents are supported by an experienced and competent manager and there are quality systems in place to make sure that they are protected. EVIDENCE: The registered manager confirmed that she has a degree in management. In addition, as a qualified nurse the registered manager has a long history in nursing and many years as an experienced manager. She works on a full-time (and beyond) basis at the home. Update training as a professional nurse is also undertaken. The deputy manager is currently undertaking the registered St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 28 managers award and discussions confirmed she is learning a lot of information and improving her management knowledge and skills. Residents spoken with confirmed that they were happy with the management of the home and felt both the registered manager and deputy manager were approachable and would sort out any problems or issues. Staff spoken with confirmed that they felt the home is well managed Information provided by the home states that the home has the ISO hospitality award in place and this was achieved recently. They are also on the preferred provider list with the local authority and have tendered and achieved a grant of £9,000.00 for improvements to the environment. As well as this, there are systems in place to monitor the quality of the service. Financial records were examined for a small number of residents and all the records were found to be accurately kept. Information provided has already confirmed that where possible, residents are encouraged to manage their own finances. The registered manager stated that all grades of staff receive supervisory sessions every 2 months. Staff spoken with confirmed this. Information provided by the home confirmed that all the servicing, maintenance and testing of equipment in the home takes place. Confirmation has also been provided that there are policies and procedures in place, as required under the regulations, and these were last reviewed in 2007. There is an ongoing Statutory Enforcement Notice issued by the Fire Department but this is being addressed by the company. The accident book was examined and advice given that the front sheet duplicates information and it may be worth reviewing to see if there were a way of addressing this duplication and thereby saving staff time when completing. Accidents are recorded accurately and the appropriate action is taken by the home. St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 X 2 St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? no 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 OP15 Regulation 17(2) Schedule 4(13) Requirement The home must maintain a record of food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise and of any special diets prepared for individual service users. The programme of refurbishment must continue and address the issues raised at the time of the inspection site visit. The registered provider must provide a programme which provides a timescale for the refurbishment of ensuites that are in a poor condition. The situation around water leaking in through windows must be addressed as a matter of priority The registered provider must confirm when the work outlined in the Fire Department’s Statutory Notice has been completed A system must be developed so DS0000006155.V341714.R01.S.doc Timescale for action 31/08/07 2. OP19 23(2)(d) 30/09/07 3. OP19 23(2)(b) 30/09/07 4. OP38 23(4)(c)(i ) 31/12/07 5. OP38 13(6) 30/09/07 Page 31 St Wilfrid`s Hall Nursing Home Version 5.2 6. OP27 18(1)(a) that the front door is kept secure, thereby protecting residents, but residents that are able to do so can enter and leave the building freely. Staffing levels in the evening 14/09/07 must be reviewed so that supervision (dependent on need) is provided to residents 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 OP12 Good Practice Recommendations The activities programme should continue to be developed and should include outings for residents. The home should consider a way of informing relatives of activities provided within the home The medical consent assessment form should be reviewed so that understanding and capacity are included Training of staff should include an awareness of needs to enhance staff empathy of residents needs Residents should continue to be included in menu decisions and personal wishes (i.e. more salad, more fruit) should be addressed A programme of replacing old beds should continue The results of quality surveys should be made available for the residents and their relatives, by posting these on the home’s notice board 2. 3. 4. 5. 6. OP9 OP30 OP15 OP24 OP33 St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Wilfrid`s Hall Nursing Home DS0000006155.V341714.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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