Inspection on 24/11/05 for Wheathills House

This inspection was carried out on 24th November 2005.

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

The inspector 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

Wheathills House 10/08/07

Wheathills House 22/05/06

Wheathills House 18/07/05

Wheathills House 27/01/05

Wheathills House 16/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Wheathills House Brun Lane Kirk Langley Derby Derbyshire DE6 4LU Lead Inspector Anthony Barker Unannounced Inspection 24th November 2005 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 Wheathills House DS0000020120.V262341.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. Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wheathills House Address Brun Lane Kirk Langley Derby Derbyshire DE6 4LU (01332) 824600 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) Mr Richard Whitehouse Mr Richard Whitehouse Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Plus One (1) Day Care Place Date of last inspection 18th July 2005 Brief Description of the Service: The Home provides residential care for 23 older people with medium to low dependency.The Home is a large period house set within a rural area of Derbyshire. There is no public transport available to and from the Home. The rooms provided are single occupancy with the majority having en-suite facilities. There is a chair lift provided. Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 3.5 hours and was a routine unannounced inspection. The last inspection took place in July 2005 and was unannounced. One resident and the Manager were spoken to and records were inspected. Two residents’ files were examined but full case tracking was not undertaken on this occasion. The focus of this inspection was on progress made on the requirements and recommendations made at the last inspection. No tour of the premises was made at this inspection. What the service does well: What has improved since the last inspection? What they could do better: Each resident must have their own copy of the Home’s Service Users’ Guide and have a care plan prepared by the Home with respect to their needs. These care plans must be reviewed monthly and full consultation must take place with residents. Care plans must have more detailed risk assessments relating to nutrition, continence and skin integrity. Staff must receive training in the use of medication from an accredited source. The wishes of residents regarding the arrangements after their death must be ascertained. The Home’s complaints procedure must make it clear that complaints can be made to the CSCI at any stage. Staff must be recruited according to the Regulations currently in force and records supporting recruitment practices must be available at all times. The certificate of registration must be conspicuously displayed in the Home. Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Residents did not have their own copy of the Home’s Service Users’ Guide. EVIDENCE: The Manager said that the Home’s Service Users’ Guide had been made available to the resident group by placing a copy in the office. He said he had no plans to provide each resident with a copy of the Guide. Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 9 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 Not all residents benefited from a written plan of care prepared by the Home. Residents’ safety was not always being considered through written risk assessments regarding their health. EVIDENCE: Two residents’ files were examined as part of the case tracking process. They both had basic information about each resident at the front of the file. One related to a privately funded resident and the care plan was a helpful document - although some of the ‘Actions’ on the care plan sheet were not actually worded as actions or goals. The other file related to a care-managed resident and only contained care plans recorded by the resident’s care manager. The Manager said that the Home does not prepare its own care plans, other than for privately funded residents, and operates to the Social Services’ care plans. There was no evidence on the first file of monthly reviews or of any reviews being discussed with residents. Both residents’ files had risk assessments relating to Moving and Handling, falls and other personal matters. There was a risk assessment relating to skin integrity on the first file although advice had not been sought from the tissue viability nurse, as recommended at the last two inspections. There was no risk Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 10 assessment relating to nutrition or continence on either file. The Manager had not attended a training course on Risk Assessment as he had previously indicated his intentions to do. The Manager said that he continued to have problems finding an accredited trainer to provide staff with training in the use of medication. A suggestion was made to him in order to expedite these matters. Other aspects of Standard 9 were not assessed on this occasion. All bedroom doors had been fitted with locks for the privacy and security of residents. A form headed ‘Locks on room doors’ was seen on both files examined. These forms showed that the first resident has chosen to hold the door key while the other resident has chosen not to. Other aspects of Standard 10 were not assessed on this occasion. The two files examined had front information sheets that had a section on ‘Preference in the event of death’. However, this section had not been completed on either file. The Manager said that some residents’ relatives had informed him of preferences but this information was not directly sought from residents. Other aspects of Standard 11 were not assessed on this occasion. Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 11 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): 15 Residents were receiving an appealing diet in pleasing surroundings. EVIDENCE: A brief visit was made to the dining room and residents were sensitively approached about their views on the food. Their positive response reinforced the Inspector’s observation of an appealing meal set out on attractively laid out tables with condiments and gravy boats in a most pleasant room. Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 12 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 Residents and their relatives were unaware of their right to make a complaint, about the Home, to the Commission at any stage. EVIDENCE: A copy of the Home’s complaints procedure was placed by the visitors book in the entrance hall. The Manager said that a copy is given to residents, at the time of admission, with their Statement of Terms and Conditions. The wording of the procedure implied that complaints could only be made to the Commission if complainants were unsatisfied with the Home’s response to their complaint. This inappropriate wording was pointed out to the registered person in June 2004. An Immediate Requirement Notice was issued at this inspection. Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 13 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): 22 Residents have some specialist equipment to maximise their independence. EVIDENCE: The Environmental Risk Assessment folder made reference to refurbished rooms and a complete re-painting of the exterior of the premises. Other aspects of Standard 19 were not assessed on this occasion. The Manager said he had given serious consideration to the purchase of a mobile hoist but had decided against it due to the low level of physical dependency of residents. He added that he had undertaken an assessment of the Home’s corridors regarding the suitable siting of handrails in corridors that had none. He anticipated these would be fitted by February 2006. Thermostatic control valves had been fitted near hot water bath taps to reduce the risk of scalding. A Legionnalla assessment had been completed by an outside firm and samples of water taken were all found to be negative. Other aspects of Standard 25 were not assessed on this occasion. Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 14 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): 29 Residents were being left unprotected due to poor staff recruitment practices. EVIDENCE: The file of one member of staff, appointed in July 2005, was examined. This was the most recently appointed staff member. It included a photograph, birth certificate and CRB disclosure. The Manager said that the job application form and references were elsewhere and could not be found. It was therefore not possible, as at the last two inspections, to assess whether the Home’s recruitment procedures met the standards. This was particularly concerning given the weaknesses in these procedures identified at previous inspections. Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 15 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): 37 The registered person was not fully carrying out his legal responsibilities. EVIDENCE: The Manager’s approach to this inspection was not always open and positive. He said that his residents “don’t like to have strangers wandering around their home”. An offer was made for the current inspector’s photograph to be taken and displayed, as is a feature at some other care homes. He declined this suggestion. The management approach of the Home, as perceived by residents and staff, was not assessed at this inspection. The Home’s registration certificate was not prominently displayed but was located on a wall in the Manager’s office. Other aspects of standard 37 were not assessed on this occasion. Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 16 A folder of recorded environmental risk assessments was examined. These were comprehensive. Other aspects of standard 38 were not assessed on this occasion. Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 17 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 2 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X X X X 3 X X X X STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X 2 X Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 18 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 OP1 Regulation 5(2) Requirement Timescale for action 01/03/06 2 OP7 3 OP7 4 OP8 5 OP9 The registered provider must suppy each resident with a copy of the Homes Service Users Guide. (Previous timescale was 01/12/05) 15(1) The Manager must prepare a written care plan for each resident regardless of funding status. 15(2)(b/c) A monthly review of care plans must occur as stated in Standard 7 and residents must be consulted within the preparation and review of care plans.(Previous timescale was 1/11/04) 13(4c)17 Assessment of residents (1a)Sc33 nutritional intake, continence mn management and the risk of developing pressure sores must be recorded in sufficient detail. (Previous timescale was 1/10/05) 13(2) The registered provider must 18(1ci) provide training in the use of medication to all staff who are required to administer medication as part of their duties, and provide written DS0000020120.V262341.R01.S.doc 01/01/06 01/01/06 01/01/06 01/02/06 Wheathills House Version 5.0 Page 19 6 OP11 12(2)(3) 7 OP16 22(7) 8 OP21 23(2j) 13(3) 9 OP27 17(2) Sch 4.7 10 OP29 19(1b) Sch2 11 OP29 17(3)(b) evidence that such training has taken place.This training must be provided by an external creditable source and involve an assessment of carer competence.(Previous timescale was 1/11/04) The registered provider must ascertain the wishes of residents regarding arrangements after their death, and record these wishes on care plans.(Previous timescale was 1 November 2004) The registered provider must provide a written complaints procedure that makes clear that complaints can be made to the CSCI at any stage.The written complaints procedure should be prominently displayed in the Home.(Previous timescale was 1/9/04) All toilet areas must have wash hand basins.(This requirement was not assessed - previous timescale was 1 November 2004) The staffing rota must indicate when care staff undertake domestic duties, the functions of staff (ie. care, domestic, catering), the person-in-charge of each shift and the Manager’s hours.(This requirement was not assessed - previous timescale was 1 August 2004) The registered person must ensure that all nine items contained within the revised Schedule 2 of the Regulations, are acquired and made available for inspection in respect of new and existing staff. (Previous timescale was 1 December 2005 – it had not expired at the date of this inspection) The Registered Person must DS0000020120.V262341.R01.S.doc 01/03/06 02/12/05 01/02/06 01/01/06 01/03/06 01/01/06 Page 20 Wheathills House Version 5.0 Sch.4 12 OP32 13 14 OP37 OP37 15 OP38 ensure that all records are at all times available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home.(Previous timescale was 1 March 2005) 24 The registered person must ensure that staff meetings are held on a regular basis and recorded.(This requirement was not assessed - previous timescale was 30 January 2004) CSA28(1) The certificate of registration must be kept affixed in a conspicuous place in the Home. 17(2)Sch4 The registered provider must ensure that all records required by Schedule 4 of the regulations are kept in the Home.(This requirement was not assessed previous timescale was 1 November 2004) 13(4)(c) The registered provider must arrange for all equipment used by, or supplied for the benefit of, residents to be subject to a regular service agreement.(This requirement was not assessed previous timescale was 1 October 2004) 01/02/06 01/01/06 01/02/06 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP8 Good Practice Recommendations The ‘Actions’ on the care plan sheet should be worded as actions or goals. Contact should be made with the Tissue Viability and Risk Nurse for further advice regarding the assessment of skin integrity and nutrition.(This was a recommendation from DS0000020120.V262341.R01.S.doc Version 5.0 Page 21 Wheathills House 3 4 5 OP8 OP11 OP12 6 OP14 7 8 9 OP15 OP19 OP21 10 11 OP22 OP24 12 OP26 13 14 OP26 OP26 15 OP28 16 OP29 27 January 2005) The registered person is recommended to attend a course on risk assessment. Staff should ascertain the religion of service users on admission.(This was a recommendation from 27 January 2005) For service users who are unable to attend pub trips, a daily programme of activities should be implemented, following consultation with them.(This recommendation from 27 January 2005 was not assessed) The registered person should inform all Service Users/representatives, in writing, of their right to access personal records held by the Home.(This recommendation from 17 November 2003 was not assessed) The registered person should consider his approach to the inspection process in order to improve the outcomes of inspections. A mirror should be provided within one ground floor toilet.(This recommendation from 16 June 2004 was not assessed) It is advised that consideration is given to bringing toilets and bathrooms in line with the otherwise good standards of décor within the Home.(This recommendation from 27 January 2005 was not assessed) It is recommended that a mobile hoist is purchased in order to reflect increases in physical dependency of residents. Each resident should have a lockable storage facility in their bedroom. (This is a requirement if a resident holds their own medication)(This recommendation from 16 June 2004 was not assessed) The registered person should review the allocated domestic hours to provide domestic cover 7 days per week.(This recommendation from 16 June 2004 was not assessed) Staff should ensure clinical waste is dispose of correctly.(This recommendation from 27 January 2005 was not assessed) In the interests of good hygiene, it is advised that liquid soap is used in communal areas and that bar soap is restricted to individual service user use.(This recommendation from 27 January 2005 was not assessed) The registered person should ensure that 50 of staff are trained to National Vocational Qualification level 2 by the year 2005.(This recommendation from 16 June 2004 was not assessed) The registered provider should review his job application DS0000020120.V262341.R01.S.doc Version 5.0 Page 22 Wheathills House 17 OP30 18 OP30 19 OP31 20 OP33 21 OP38 form so that gaps in applicants’ employment records are clearly identified.(This recommendation from 16 June 2004 was not assessed) It is advised that supervision forms include a section to record all mandatory training requirements and how the Home will meet these.(This recommendation from 27 January 2005 was not assessed) It is advised that timescales are added to the induction form to ensure that the induction is completed in a timely way.(This recommendation from 27 January 2005 was not assessed) The registered manager/proprietor should complete the National Vocational Qualification level 4 in management and care by 2005.(This recommendation from 16 June 2004 was not assessed) The registered provider’s Annual Development Plan should be broadened to include all aspects of the running of the Home.(This recommendation from 16 June 2004 was not assessed) The entries in a Health and Safety annual audit should be dated to give it validity.(This recommendation from 16 June 2004 was not assessed) Wheathills House DS0000020120.V262341.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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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