Inspection on 02/02/06 for Wickwar Nursing & Residential Home

This inspection was carried out on 2nd February 2006.

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

Wickwar Nursing & Residential... 15/02/07

Wickwar Nursing & Residential... 02/08/05

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Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Wickwar Nursing & Residential Home Castle House Sodbury Road Wickwar South Glos GL12 8NR Lead Inspector Grace Agu Unannounced Inspection 2nd February 2006 09:05 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 Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 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. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Wickwar Nursing & Residential Home Address Castle House Sodbury Road Wickwar South Glos GL12 8NR 01454 294426 01454 294936 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) Ashbourne (Eton) Limited Mrs Amanda Waldron Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. May accommodate up to 35 persons aged 65 years and over requiring nursing care. May accommodate up to 20 persons aged 65 years and over requiring personal Care only. Manager must be a RN on part 1 or 12 of the NMC register. Staffing notice dated 30/05/2001 applies. May accommodate up to 3 persons aged 50 years and over requiring nursing care. 2nd August 2005 Date of last inspection Brief Description of the Service: Wickwar Nursing Home is owned by Ashbourne Healthcare and is situated on the Sodbury Road in the village of Wickwar. There is a bus service up to 3 times a day. The village has a post office, hairdresser, coffee shop, newsagent and public house. The home is a converted property providing accommodation on 2 floors; there is adequate lift access. There are single and double rooms; all have a wash hand basin, but there are no en-suite facilities. Communal space is spread across seven areas. Utility /bathroom areas are well equipped for the residents assessed needs in the home. There is an activities organiser and regular activities are arranged. The home is pleasantly situated and has a well-maintained garden that is enjoyed by the residents. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is an unannounced inspection which was undertaken over eight hours to review the requirements made at the last inspection and also to review the care practice to ensure that it is in line with the legislation and that best practice is followed at the Home. At the last inspection one requirement was made in relation to storage of medication. Medications reviewed evidenced that this requirement had been met. A tour of the building was undertaken and a number of records were viewed. Eleven residents, seven staff members and one relative were spoken with at the Home on the day. The Home had recently been taken over by a new provider (Southern Cross) the Manager stated that the standard of care at the Home will remain high. What the service does well: Generally the Home was found clean, warm, well lit and free from unpleasant odours. The atmosphere of the Home was noted to be relaxed. Residents looked well cared for and staff were noted interacting with residents in an informal and personalised manner. At a discussion, the Manager stated that the Home continues to maintain high standards of care through regular care review. The relationship between staff and residents remain informal and cordial including the relatives. The home continues to provide good training for its staff both internally and externally to ensure that the needs of the residents are met. One staff member spoken with stated that there is good team building at the Home; this made a great impact in the care of the residents. Residents enjoy good nutritious food this had contributed to their feeling of wellness. This was evident on the day. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: To ensure that care needs of identified residents are met it would be better to Provide appropriate care plans and ensure that one resident is referred for further professional management. One identified staff member would be enabled to perform the duties effectively if regular formal documented supervision is provided. Satisfactory explanation and implementation in relation to the above requirements was received at the Commission before the report was completed. The requirements have been removed and will be reviewed at the next inspection. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 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. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 The home provides information to prospective and their representatives and ensures that the admission process provides safe guards to meet the assessed needs of the residents. EVIDENCE: The Home has a Statement of Purpose and Service User’s Guide, which contains information required by the regulations. The Service User’s Guide is given to prospective residents and/or their relatives when they visit the Home or make enquiries to enable them to make informed decision about moving into the Home. Whilst touring the building, it was noted that rooms viewed had a folder which contained, the Statement of Purpose, Service Users Guide, Terms and Conditions of their stay, complaints procedure, letter confirming that the Home is able to meet their needs, additional information on frequently asked questions and a copy of the last inspection report. The Manager stated that Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 10 this is to ensure that all the residents and their relatives have detailed information about the Home. Review of the care file of a recently admitted resident showed that the resident was assessed before moving to the home to ensure that their needs will be met. A copy of the Terms and Conditions was also noted in the file. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11. The Home offers care and support to residents throughout their lives and towards the end. It also protects residents by review of their health needs; good care planning and appropriate medication administration. EVIDENCE: Three care files were reviewed. There was evidence of pre-assessment of residents before admission to the Home to ensure that their needs are adequately met. There were individualised care plans to match the needs, these care plans described in details how the needs were met through the entries noted in the daily report. Residents spoken with stated that they are well cared for and that “staff treated us with dignity and respect”, “I decide when I get up and retire” and “staff help me when I ask them”. One of the care files reviewed had a care plan for medical condition with an input from a health professional. A strategy in relation to how to enable the staff to meet the resident’s specific need was in place. However, it was noted that one of the strategies was not being used. This was not detrimental to the Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 12 residents’ wellbeing, it was agreed that the strategy should be reinstated to ensure that the needs are being met, as planned by the health professional. A confirmation that this has been reinstated was received at the Commission before this report was completed. It was also agreed that one resident with another medical condition should be referred to the General Practitioner (GP) for appropriate professional input. The home sent a written explanation, which stated that the identified resident was seen by a health professional and was discharged from their care in 2004. The health professional will review the individual as soon as possible. Other care plans seen were regularly reviewed. The accident book confirmed that all accidents were well documented and were regularly reviewed. The Manager undertakes monthly accident audit to ensure that measures are in place to prevent reoccurrence. All residents have risk assessments including tools for assessing falls and falls prevention. Evidence from the care files and discussions with residents and staff showed that residents have visits from their GPs, physiotherapists, dentist, opticians and speech and language therapist. A medication review showed that new and bigger trolley had been purchased to accommodate more medication and to reinforce the safety of drugs. It was pleasing to note that the requirement made at the last inspection in relation to storage of medication had been met. All other medication administration practices were satisfactory. Evidence of residents’ wishes in the event of death was noted in the care files viewed. The home also had a death and dying policy. Staff interviewed were aware of the importance of ensuring that all information about residents are kept confidential. Staff are also aware of the policies and procedures and where to access them if needed. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. The Home enables the residents to maintain contact with families, friends and the local community. It provides meaningful activities and choice in respect of meals and meal times. EVIDENCE: Evidence of discussion with resident staff and entries in the visitors’ book showed that the Home actively supports the residents to maintain contact with families, friends and advocates. One resident spoken with stated that her family visits very regularly and that the Home would contact her family anytime she wanted them to. One relative spoken with on the day stated that there are no restrictions to time of visiting and that they visit their relative sometimes twice a day. They are satisfied with the Home and the services provided, “staff are very welcoming”, “they treat us like family”. The home continues to provide meaningful activities for the residents. Residents are assessed on an individual basis to enable the home to plan activities tailored to individual residents. The activities organiser consults with the resident/relatives on admission to obtain information on the activities preferences and regularly undertakes reviews to ensure it is still appropriate. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 14 Whilst walking round the building it was noted that the activities programme was displayed in the lounges and the hallway in the Manager’s office. The activities organiser was met and was noted to be mending residents’ clothes with a sewing machine. She stated that she finds time to mend these clothes to ensure that residents maintain their dignity whilst living in a care home. This is commendable. During a discussion, the activities organiser stated that there are “activities for everyone”. There is a list of monthly activities for special events, weekly planned activities which include outings and trips. The activities book contained lists of all the residents and activities they had participated in. This is to enable the home to monitor participation and to plan other ways to encourage those who are reluctant to participate in any activity. The activities organiser stated that she walks around the home every morning to see the residents with the menu and to inform them of the activities for the day and also provide the residents with some personal interaction with her There is a mobile shop service for resident on Friday afternoons. Also noted on the ground floor outside the Manager’s office was a craft table designed by residents. This craft table has a permanent display of craft made by residents. The sales from these crafts are donated to the residents’ fund to pay for trips and residents parties. The table also had donated items from relatives and friends. The activities organiser stated that the residents benefit from the services of the local church. The church provided Holy Communions to the residents monthly. The last one was 01/02/06. The resident always look forward to that service. There was evidence of personal possessions in the rooms viewed, one resident stated that she enjoys being in her room because she enjoys puzzle words and more importantly the peace it provides while looking at her family photographs and other personal possessions. Staff were noted knocking on doors before entering the resident room to ensure privacy. Noted outside the Manager’s office was residents information file, which included copies of most recent ‘Thank You’ letters, the most recent inspection report, minutes of the resident/relatives meetings and complaint procedure to ensure that the relatives are updated with information about the home. On the day of inspection there were two choices of meals in the menu, to include chicken casserole and toad in the hole with fresh vegetables, potatoes and Manchester Tart for pudding. Residents spoken with in the dining room at lunchtime stated that they enjoyed their lunch. Staff were noted with aprons whilst serving residents and those unable to feed themselves were seen being feed in a sensitive and dignified manner. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 15 The kitchen was found to be clean; there was a cleaning schedule in place. The home was inspected by the South Gloucestershire Council Environmental Services on 5/12/05 and was provided with a food safety award. There was a kitchen risk assessment in place. The chef showed the inspector the new dishwasher and new food processor, which was recently purchased for the Home. The chef stated that the above would provide better food hygiene and infection control for the home. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. Residents are enabled to complain and are confident that their complaint will be listened to. Practices at the Home ensure protection of resident from harm and abuse EVIDENCE: The Home has appropriate procedures in place for management of complaints. The complaints procedure was noted displayed in the hallway at the entrance. This document contains information about the Commission for Social Care Inspection to enable individuals to contact the Commission if they were not satisfied with the outcome of their complaint to the organisation. The complaints procedure was also noted in the information for relatives outside the Manager’s office and in the file kept in the residents’ rooms. The complaint procedure had been updated to reflect the new providers (Southern Cross). There had been no recorded complaint since the last inspection. The Manager stated that she sees the residents on a daily basis to provide them the opportunity to discuss with them any concerns that they may have. The Manager and staff are also readily available at the home to talk to relatives and to respond to any concerns that may be raised. Residents spoken with stated that they are aware of whom to complain to, however, have no reason to complain. One resident stated that they are aware of their rights and were enabled to vote using the postal voting system. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 17 Staff are aware of the Whistle Blowing policy and would report any bad practices to the Manager without fear of reprisal. There is evidence of staff training in relation to Protection of Vulnerable Adults from Abuse. There is a copy of the South Gloucestershire Council policy on The Protection of Vulnerable Adults from Abuse at the Home to ensure that the Home is aware of the protocol to be followed if incidences of abuse occur. Records of recently employed staff members contained statutory information to include two satisfactory references, record of previous employment, personal details and satisfactory Criminal Record Bureau disclosures. The Home ensures that all Personal Identification Numbers of Registered Nurses are checked with the Nursing and Midwifery Council before commencement of employment and periodically. Residents spoken with stated that they felt safe at the home. Residents’ money checked corresponded with the amount in the safe. It was agreed that the amount noted in the safe should be kept at a minimal to reduce risk to the Home. The administrator stated that she would consult with some of the families in relation to refunding back some of the monies in order to reduce the balance in the safe. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20,24, 26. The residents enjoy a pleasant, safe and homely environment with a good standard of hygiene. EVIDENCE: Whilst the home had recently changed providers, no changes had occurred in relation to the home’s suitability for its stated purpose on the provision of care for the residents. The residents were found sitting in the communal areas and appeared relaxed in their homely environment. The home was found clean, warm, well lit and free from unpleasant odours. The clinical waste is correctly disposed of to prevent the spread of infections. There is an infection control policy in place. One resident spoken with stated “the Home is lovely” and she likes her room because it provides her with a good view. Residents spoken with stated that they felt safe at the home. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 19 The home’s maintenance book was up to date and the maintenance person had recently attended the Maintenance Technicians course with the previous providers. The laundry area was found clean and tidy. There were adequate housekeeping staff on duty, the Senior House-keeper was in charge of the laundry on the day and had been working at the Home for a number of years. She would usually deal with any concerns from residents and relatives in relation to their clothing. Housekeeping staff have attended courses on Control of Substances Hazardous to Health (COSHH). Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The residents enjoy a good, warm relationship with competent staff. The Home’s recruitment procedure offers protection to residents. There is adequate numbers of staff to meet the needs of the residents. EVIDENCE: On the day of the inspection there were thirty-nine residents at the Home. The rota showed that there were two registered nurses 8am-2pm and eight care assistants 8am-2pm. There also two registered nurses 2pm-8pm and five care assistants 2pm-8pm. One registered nurse from 8pm-8am and three care assistants from 8pm-8am. The Manager stated that this is regularly monitored to ensure that residents’ needs are adequately met. Residents spoken with stated that staff attended to them promptly when they rang the bell and provided time for them to talk. The Home operates a key working system to enhance the resident/staff relationship. Staff training records showed that the home invests in the training of its staff to ensure that staff are aware of their roles and responsibilities and that a high standard of care is maintained. There is a Training Co-ordinator at the Home who organises training for all staff. Records showed that staff have attended training on Health & Safety, fire updates and other relevant courses. Records of the newly employed staff showed that they have received comprehensive induction training prior to attending to residents’ personal care independently. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 21 Staff spoken with stated that the training provided is very valuable. Training attended by registered nurses included training on a wound care update, Monitored Dose System (MDS) for Medication, Care Planning training (planned for 16/02/06), palliative care training and supra pubic and male catheterisation. Training proposed for 2006 by the new providers (Southern Cross) include Dementia Awareness, Communication and the role of the Commission for Social Care Inspection. Six care staff have been registered to National Vocational Qualification at Level 2. It is proposed that some staff who have attained NVQ2 qualification to undertake NVQ3 to enable them to undertake supervisory responsibilities. Recent staff recruitment showed that all statutory requirements in relation to protection of residents were met. The Home’s recruitment procedure is detailed and robust. All staff working at the Home had satisfactory Criminal Records Bureau disclosures. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37,38. The Home benefits from good leadership and management; its practices offer protection to the health and safety of residents. EVIDENCE: On the day of inspection there was a friendly and interactive atmosphere in the home. Residents looked well cared for and were seen talking to staff in an informal way. This is an evidence of the Manager’s leadership and management style. Staff spoken with were very complimentary of the Manager’s ability to manage the home. Two staff members spoken with stated that the Manager’s warm and caring personality had facilitated their long service to the Home. Mrs Amanda Waldron “had been there for us”. The Deputy Manager stated that she had received support from the Manager and that she has learnt many things from her. Other staff members stated, “The Manager is always willing to help”. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 23 Residents at a discussion stated that the “Manager is kind. “She comes to see us every morning”. “ I talk to her about my concerns and she quietly deals with it”. Evidence from staff records showed that staff have received regular supervision. The Manager stated at a discussion that the Deputy Manager had received informal supervision, however, this is not documented. It was agreed that the Deputy Manager should receive documented formal supervision to enable her to express her concern on areas of responsibility and to receive feedback on her performance. Evidence that the Deputy Manager had received documented supervision on 6/2/06 was sent to the Commission for Social Care Inspection. Future planned supervision for all trained nurses and including the deputy manager was also received at the Commission. The fire logbook was noted to be well maintained and up to date. Staff have attended fire lectures and regular fire drills. All staff responded appropriately at the sound of the fire alarm on the day. The Home has a comprehensive general risk assessment to cover all areas of the Home. It was agreed that the carpet on the short corridor between the administrators office, staff room and staff toilet be replaced in the future to avoid hazardous situations for staff members. Quality assurance for the Home was reviewed. The Manager stated that the Home audits its service through regular questionnaires to residents and relatives; care plan reviews; resident and staff meetings; daily visit to residents by the Manager; comment cards from visitors. There is also monthly medication audit, weight, accidents, pressure sores, death and Managers monthly audit to cover care documentation, complaints, and maintenance, training records and Health and Safety. The Manager stated that she had recently completed the Registered Managers Award and that her tutor will visit on 15/03/06 at the Home and will present this certification to her. The Manager stated that she feels very passionate about the Home and would continue to ensure that the standard is maintained. The manager stated that whilst she had no supervision from the previous providers however had support from the Operations Manager; Southern Cross Healthcare had arranged supervision for her before the end of January. Unfortunately she was of sick. This will need to be rearranged. She had been well supported by staff to carry out her leadership responsibilities. The Home has policies and procedures to include complaints, missing persons, risk assessment, whistle blowing, Protection of Vulnerable Adults and Health and Safety. Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 24 Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 25 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 3 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 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 3 3 4 Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wickwar Nursing & Residential Home DS0000065198.V276243.R01.S.doc Version 5.1 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!