Inspection on 08/11/07 for Wey House Nursing Home

This inspection was carried out on 8th November 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wey House Nursing Home 12/05/09

Wey House Nursing Home 24/04/08

Wey House Nursing Home 27/06/07

Wey House Nursing Home 17/01/07

Wey House Nursing Home 01/06/06

Wey House Nursing Home 28/10/05

Wey House Nursing Home 09/06/05

Wey House Nursing Home 14/01/05

Wey House Nursing Home 11/06/04

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

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

CARE HOME ADULTS 18-65 Wey House Nursing Home Norton Fitzwarren Taunton Somerset TA4 1BT Lead Inspector Gail Richardson Unannounced Inspection 8th November 2007 09:30 Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 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 Wey House Nursing Home DS0000003310.V354403.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wey House Nursing Home Address Norton Fitzwarren Taunton Somerset TA4 1BT 01823 337391 01823 326652 sandra.whitfield@robinia.co.uk 26stmarksroad@robinia.co.uk The Robinia Group PLC 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) Miss Helen Angela Smith Care Home 37 Category(ies) of Physical disability (37) registration, with number of places Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing- Code N to people of either gender whose primary care needs on admission to the home are within the following category: 2. Physical disability- Code PD The maximum number of service users who can be accommodated is 37. Date of last inspection Brief Description of the Service: Wey House is a Registered Care Home with Nursing for younger adults with acquired brain injuries and progressive neurological diseases. The home is on the outskirts of Norton Fitzwarren, 5 miles from Taunton and is set in large grounds. There is an area of fenced garden to the front of the house. The accommodation is divided into three units. The home has wide corridors and good size communal rooms. All bedrooms are 12 sq.metres or more in size. Two bedrooms in unit one have steps and are accessible by stair lift. All other areas of the home are accessible by lift. The home is suitably adapted for the client group accommodated. The home has a large hydrotherapy pool and dedicated physiotherapy staff. There is a skill mixed team of professional staff and care workers. The current fee ranges from: £560 to £1600 per week. Hairdressing and aromatherapy. Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over 2 days (18 hours) on the 8th and 9th November 2007 by inspectors Gail Richardson and Sally Murphy. There were 30 people using the service residing at the home which included 1 person admitted for respite stay. The Inspectors viewed a selection of bedrooms and all communal areas of the home, viewed records in relation to care and support plans, staff recruitment, health and safety and medicines records. The Inspectors spoke to 4 people using the services and 6 staff. All staff that spoke with the inspectors appeared more settled and confirmed that morale at the home was improving. Surveys were received from 12 people using the service,6 surveys were received from relatives and visitors, 5 from staff . On both days of inspection the home appeared busy with people being supported by staff to attend dental appointments, visit the college and receive support visits from outside agencies. The atmosphere appeared well organised and active. What the service does well: The provision of activities has increased in both content and frequency to support the preferences of the people using the service. Staff confirmed this is due in part to the increase in staffing levels and the registered manager confirmed her input in activity organisation. The standard of food appeared very good with 2 meals observed by inspectors. These observation noted a good standard of food quality and showed that kitchen staff have a good understanding of peoples preferences The environment of the home continues to improve and the home appears to have developed to support the people using the service with specialist equipment and environmental changes made to support peoples choices and abilities. Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The statement of Purpose and Service User Guide is required to be reviewed . This is required to ensure that prospective people using the service are aware of the range of services available within the home. The home is recommended to review contracts to contain all details related to Schedule 4 of the Care Homes Regulations 2001 to ensure that people using the service are aware of all purchasing agreements. Care plans require further development to ensure that staff have detailed information to support them to give personalised care in all areas identified. MAR sheets were generally well maintained but it was noted that some hand transcribed medications did not have a date and 2 signatures. This is required to ensure the safe administration of medication. The call bell system was found to not be functioning correctly in some areas of the home. Suitable means for people using the service to attract staff attention must be in place and the repair/ replacement of the call bell system be undertaken as planned. Recruitment records were examined and were mostly complete but evidenced one unexplained gap in employment history. One application form was not signed and dated. All recruitment procedures are required to be complete to ensure that people using the service are not at risk of abuse. The Adult Protection Policy for Somerset must be followed to ensure that people using the service are suitably protected and not placed at risk. Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 3 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is currently updating the information available within the Service User Guide and Statement of Purpose for prospective people using the service to be able to make an informed decision about the home. All prospective people using the service receive a pre admission assessment by the registered manager and are able to visit the home prior to admission. The contracts used by the home do not contain all the details required. EVIDENCE: Surveys asked, did you receive enough information about the care home before you moved in so you could decide if it was the right place for you? 5 relatives said they usually received enough information, 9 people using the service said they received enough information One person using the service survey said’ They should have given you more information about the home’. The home has recently admitted a person who’s age is above the usual age group residing at the home. The Statement of Purpose does not reflect that the home provides a specific service for older people. The registered manager confirmed and evidence was seen that this issue is being reviewed to include Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 10 this information within the Statement of Purpose. This is required to ensure that prospective people using the service are aware of the range of client group and the services available to support all people using the service. The home has admission and assessment polices and procedures in place which were seen to have been followed. Contracts were examined and did not contain the details of the room to be occupied or the fees charged. The registered manager stated that when the refurbishment of the home was complete, the contacts would be reviewed to contain the correct information. Disclaimers are now in place for each person using the service who is not able or has no representative available to sign their contract. Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 9 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans require further development to ensure that staff have detailed information to support them to give personalised care in all areas identified. People using the service are supported to make decisions and choices about their life and are actively involved in some aspects of the home. Risk assessments are used to support people using the service to maintain their independence. EVIDENCE: The Inspectors viewed 5 care plans including the plan of the person most recently admitted for respite care. The home provides each person using the service with a personal profile which is available both in their room and in their care plan. This profile is detailed providing staff with a clear account of each person using the services abilities, Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 12 choices and aspirations and covers aspects of personal and social support. The registered manager confirmed that this new system of profiling and care planning is in its early stages and is being assessed and developed. Records identified when people using the service had received visits from health care professionals including GP’s, Chiropodist and Dentists. The Inspectors viewed day-to-day records of the care given to each person which were up to date but it was noted on 2 instances that matters affecting the person using the service had not been recorded. The storage of all records within the home is in line with the Data Protection Act. Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11 12 13 14 15 16 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are now offered a wider range of activities and experiences both in and out of the home. It appears that good links are maintained with relatives. The home provides a varied menu of good quality food which is reflective of people using the service preferences and choices. EVIDENCE: Leisure activities include Karaoke, review of newspapers t.v .and videos. The Registered manager confirmed that home supports trips out. The home has a hydro pool and full time physiotherapy staff and it was confirmed that some people using the service have access to the pool with assistance. Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 14 Activities are now organised by the registered manager and staff were noted to be involved in review of newspapers and karaoke. Staff were seen to support people using the service to visit the dentist and hairdresser. Individual records are being developed to record all of the activities that each person has accessed. One person using the service said, ”There are not enough activities for me” and one survey commented on how staffing levels affected the person from accessing some activities. The home enables some people using the service to go to college and also has a visiting IT facility to enable people to develop IT skills within the home. The manager later confirmed that the college provides a weekly art session at the home offering an additional opportunity for those who may not be able to attend college or wish to take part in further activities. The home supports people using the service to take trips. It appears that there are good links with the relatives. Some comments received from relatives and visitors stated that they are kept informed about important matters that affect their relative and they are made to feel welcome at the home. The inspectors observed an evening meal and lunch the next day. Both meals were varied in choice and were reflective of peoples preferences and choices. The cook demonstrated a wide knowledge of people using the service’s likes and dislikes. Specialist diets were catered for and puree diet is served in individual portions to ensure that people using the service can identify different tastes and textures. The routine of mealtimes has improved since the previous inspection with a well organised routine which supported both people who ate independently and those people who required assistance with eating and drinking. Nursing staff monitor weight gain and loss by weighing people monthly to maintain health and well being. Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service receive support in the manner they prefer and the home ensures that they have access to all appropriate health care professionals, some records relating to support require further review. Good records are maintained in relation to the administration of medicines with only one area noted to require further attention. EVIDENCE: The care profiles indicated the manner in which people preferred to receive their personal care and the daily record within the care plans reflected that this was what happened. The care plans examined showed some improvement from previous inspection but require further development to ensure that all areas of assessed needs were appropriately care planned. This is necessary to ensure that staff are able to provide detailed and up to date care as required. Some areas of care planning were not up dated to reflect the actual care being received and this was discussed at inspection with the manager. This included Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 16 one instance of assistance with personal hygiene, mobility and sleep. One care plan did not reflect an agreed vulnerable adult strategy in all areas of care in which an identified risk is possible. Two care plans were noted to be out of date as they stated that the service users clothes were stored in the laundry, whereas this practice has ceased and clothes had been stored in the person’s bedrooms. Further areas of need were not care planned which included a person with an acquired infection and one person requiring wound care. Further areas within the care plans required updating to ensure that correct personal care and mobility details were available for staff to follow. People were seen to be dressed in a manner of their preference and all people using the service’s personal hygiene appeared well care for. All people using the service have an allocated key worker. There was evidence within the care plans that staff are proactive in involving multi-disciplinary healthcare professionals, including appointments with chiropodist, opticians and GPs. Records are kept of all visits. Surveys from relatives and visitors were asked, Do you feel the care home gives the support or care to your relative that you expected or agreed ? 3 always, 3-usually and 1- sometimes. One relative commented “Excellent communication, when admitted to hospital, the staff always ring me as soon as possible”. People using the service surveys asked, do the carers listen and act on what you say? 5-always, 2-sometimes and 2-hardly ever. The Inspector viewed the arrangements in relation to the storage, administration and disposal of medicines. The systems in place were mostly satisfactory and improvements were seen in the organisation of audits and review of storage of medications. MAR sheets were generally well maintained but it was noted that some hand transcribed medications did not have a date and 2 signatures. This is required to ensure the safe administration of medication and is required to be reviewed. Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure and there are policies and procedures to safeguard vulnerable people. Induction must be completed by all staff to include Safeguarding policies. Safeguarding Vulnerable adults policies have not been followed to protect people using the service. EVIDENCE: The home has a complaints procedure and the registered manager maintains a log of concerns which indicted that all complaints and concerns are responded to within a reasonable timescale. People using the service were clear about who to complain to and those spoken with and surveys received confirmed that relative knew how to make a complaint. CSCI have received 6 concerns/complaints since the last key inspection and have one ongoing Vulnerable Adults strategy in place. The home have received 7 concerns/complaints. During the inspection it was observed that the management of the home have not completed a previous investigation. This is not in line with Adult Protection procedures and does not protect the people using the service from the risk of harm. Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 18 The staff who spoke with the Inspector were aware of the home’s Whistle Blowing Policy and Complaints Policy. The home has a whistle-blowing policy which is recommended to include the contact details of CSCI. It was noted in one staff file that induction had not covered the complaints and whistleblowing policies for that member of staff. Detailed records are kept at the home of all people using the service individual expenditure with receipts obtained wherever possible. The inspector audited 3 financial files and all monies stored were correct. Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 26 27 28 29 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home appears comfortable and safe with evidence of wear and tear associated with a house of this level of usage. People’s bedrooms viewed reflected individual needs and lifestyles and promote privacy and dignity. The home provides the specialised equipment required as assessed. The home provides a clean and hygienic environment. EVIDENCE: Wey House is an old house which has undergone some maintenance and refurbishment which includes an extension. The manager confirmed that since the last key inspection various bedrooms have undergone redecoration. Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 20 The home has a main lounge area downstairs with a dining area and a lounge upstairs. Inspectors observed people using both public rooms and both rooms appeared suitably furnished and comfortable. The bedrooms that were viewed reflected people’s individual needs and lifestyles. All appeared very well maintained, comfortable and were furnished with soft furnishings of person’s choice. The maintenance staff explained that people using the service have the choice of room colour and décor. Some rooms were awaiting new carpets, all en-suite facilities are now fitted with individual store cupboards. Two upstairs windows were observed to open to a wider space than is recommended by the Health and Safety Executive. Restricted chains were fitted but had not been secured. This was brought to the attention of the registered manager at inspection. The home has an attractive garden area which has been adapted to allow wheelchair access. On the day of the inspection the home was clean and hygienic. Hand washing facilities are provided in all appropriate areas. There are adequate laundry facilities and staff are aware of infection control procedures in the laundry. The inspectors were advised by staff that one person using the service was found 3 times that day in the staff area of the home. Inspectors visited the staff area and found that there was access to an unrestricted window, cleaning solutions hazardous to health, electrical equipment, water exceeding 43 degrees, uneven flooring and personal information/records relating to all people using the service. An Immediate Requirement was made to prevent access by people using the service to these risks under Regulation 13(4) of the Care Homes Regulations 2001. On the second day of inspection it was confirmed that the door had been repaired the previous day and it was observed that restricted door access had been put in place and the window had been restricted. The call bell system was found to not be functioning correctly in some areas of the home. The inspector tested the system where a person using the service had found it not to work correctly. The registered manager confirmed that quotes for a new system had been received and that where identified the people using the service were supplied with alternative means of alerting staff attention. Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. On the day of the inspection the home appeared appropriately staffed to meet the needs of the service users. The recruitment processes are in place but require further details to be included to ensure the people using the service are not at risk of abuse. Staff receive regular formal supervision. EVIDENCE: On the day of inspection there were 10 staff on duty plus 2 qualified staff and the registered manager. There were 9 care staff plus 2 qualified staff on duty in the afternoon and 2 qualified staff and 4 care staff on night duty. The home has recently increased staffing levels to meet the dependency of people using the service and has stated the intention to review the dependency level and to continue to inform CSCI if the staffing level drops below the agreed level for whatever reason. Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 22 The Inspectors spoke to a number of staff at the time of the inspection and received a selection of surveys. Comments received included “At the moment we have good staffing levels, but sometimes we are short of staff. Sometimes, one or two support workers will call off sick, half hour before the start of shift and of course there is no time to call the agency to cover the shift.” and “I think we provide the highest standard of care for our clients. The service has improved in the past few months, a lot of changes.” Staff training is ongoing and staff files evidenced that whilst most mandatory training is in place, some areas are out of date, a plan is in place to rectify this. This area will be revisited at the next inspection. 5 care staff have achieved NVQ level 2 and 2 care staff have achieved NVQ level 4. This total does not reach the 50 required by the Nation Minimum Standards. Staff spoken and surveys received, confirmed that staff had received induction 1-very well, 2 mostly and 2 partly. One staff file noted that induction had been commenced but not been completed within a wide timescale to include adult protection policies. Recruitment records were examined and were mostly complete but evidenced one unexplained gap in employment history. One application form was not signed and dated. Risk assessments are now in place for any identified issues raised from employment checks. Staff confirmed that they receive regular formal supervision where they are able to identify personal training needs and discuss matters pertaining to the home. The records of this supervision were seen and the supervision form contains all the topics indicated in the National Minimum Standards. Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38 39 40 41 42 43 Quality in this outcome area is good . This judgement has been made using available evidence including a visit to this service. The home appears to be well managed with clear leadership and direction. The Health and safety management within the home is well maintained and recorded. EVIDENCE: The manager Helen Smith has been employed in post for almost 12 months and has implemented changes that are having a positive effect on the running of the home. Staff meetings take place and staff confirmed that these are an opportunity to discuss opinions and concerns. One staff comment received stated “Helen our manager is doing her best for the benefit of the residents, family home and the company” and Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 24 “There was a lot of changes and a lot of improvement in all aspects of service and care to the residents.” The inspector examined quality assurance records, which are being collated in November 2007, which reflected the opinions of the people using the service. The inspector will review the audit at the next inspection. Robinia has comprehensive policies and procedures that are readily available at the home. All records seen by the Inspectors were well written, up to date and appropriately stored. The home keeps records of all incidents and accidents and the Manager reviews them before they are sent to Head Office for further audit. The inspector recommends that the manager document the action plan as a result of the review. The Inspectors viewed the following records relating to health and safety: All records maintained were clear and well recorded. • • • • • • • • Monthly Legionella checks Hard wiring certificate Gas servicing certificate PAT testing records COSHH records Fire risk assessment Fire service records including fire extinguishers, weekly fire tests, staff fire training Emergency lighting checks Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 1 2 3 3 3 4 3 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 1 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 3 3 3 3 3 3 1 x Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 26 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4(1)(b) schedule 1 Requirement Timescale for action 30/01/08 2. YA5 17(2) Schedule 4 3. YA6 15(1)(2) 4. YA20 13(2) The registered manager is required to ensure that the Statement of Purpose and Service User Guide contain all the information required to ensure that prospective people using the service can make an informed decision about the home. This is with reference to details of services available for people outside of the registration category. The registered manager is 30/12/07 required to review the content of the contracts in use to ensure that people using the service are aware of the details of their contacted residency. Care plans are required to be 30/12/07 further developed to ensure that all areas of assessed need have an up to date care plan which is accurate and reflects the area of identified The registered manager is 30/12/07 required to ensure that all hand transcribed medications are signed by 2 staff to ensure there is no risk of incorrect medication administration. DS0000003310.V354403.R01.S.doc Version 5.2 Wey House Nursing Home Page 27 5. YA23 12(1)(a)(b) The management of the home 30/12/07 are required to completed any ongoing investigation in line with Adult Protection procedures to ensure that the home protects the people using the service from the risk of harm. 12(1((a)(b) The registered manager is required to ensure that the call bell system is functioning in all areas and that any repair/replacement is undertaken as needed. 12(1)(a) The registered manager is required to ensure that all areas of health and safety are maintained and updated .This is with reference to upper floor windows which open in excess of the health and safety recommendation. 19(1)(b) The registered manager is required to ensure that recruitment procedures protect service users from any risk of abuse. All gaps in employment history are explored and documented. All recruitment forms are signed and dated. 30/12/07 5. YA29 6. YA42 01/01/08 7. YA34 01/01/08 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 YA23 Good Practice Recommendations The registered manager is recommended to ensure that DS0000003310.V354403.R01.S.doc Version 5.2 Page 28 Wey House Nursing Home policies used within the home regarding whistle blowing contain the contact details for CSCI 2. YA24 As agreed and in line with the company’s refurbishment plan maintenance work must continue throughout the home. The registered manager is required to ensure that 50 of staff achieve NVQ level 2 to support people using the service. The registered manager is strongly recommended to ensure that staff complete the induction within a stated timescale of commencing employment. The manager is recommended to document the action plan made as a result of the regular accident audit. 3. YA32 4. YA35 5. YA42 Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Wey House Nursing Home DS0000003310.V354403.R01.S.doc Version 5.2 Page 30 - 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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