CARE HOMES FOR OLDER PEOPLE
Wilbraham House Residential Home The Old Vicarage Church Street Audley Stoke On Trent Staffordshire ST7 8HL Lead Inspector
Mrs Wendy Grainger Key Unannounced Inspection 15th May 2007 08:15 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 Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Wilbraham House Residential Home Address The Old Vicarage Church Street Audley Stoke On Trent Staffordshire ST7 8HL 01782 720729 F/P 01782 720729 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) Wilbraham Limited Mrs Susan Elizabeth Cameron Care Home 33 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (33), of places Physical disability over 65 years of age (6) Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide personal care and accommodation (without nursing) for service users of both sexes whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 33 Physical Disability over 65 (PD)(E) 6 Physical Disability over 55 (PD) 2 Dementia over 65 (DE) (E) 6 The maximum number of service users to be accommodated is 33. 2. Date of last inspection 22 February 2007 Brief Description of the Service: Wilbraham House is a privately owned residential care home, registered to care for up to 33 elderly residents with a variety of dependency needs, including six residents with a mental frailty and six residents who are physically frail. At the time of this Unannounced Key Inspection, 29 residents, occupied the home. While the primary purpose of the home is to provide long-term care, short stay visits are also catered for if there is a suitable vacancy. The home came under new ownership in October 2001 and the Registered Proprietors are Mr Pargan Dhadda and Mr Sukhinder Singh Kandola. At the time of this inspection the home was being managed by Mrs Sue Cameron who has been approved as the Registered Manager for Wilbraham House. During the course of this inspection Mrs Cameron provided helpful assistance to the Inspector who was impressed with her commitment to making improvements to the quality of care at the home. The extension to the home has been completed and was in full use at the time of this inspection - providing 6 additional bedrooms, each equipped with an en suite, as well as a separate adapted bathroom and shower. Wilbraham House is well located in the village of Audley, opposite the Church and convenient for a wide range of local amenities including shops, pubs, post office, community centre and health centre. There are plans to further develop the external space to provide more user friendly and safe areas for residents to enjoy during the better weather. From the verbal information provided by the care manager the current fees for the home were £335/£390 additional cost would include any personal toiletry items purchased; private chiropody, hairdressing and any periodicals.
Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was carried out by Mrs Wendy Grainger Inspector on the 15 May 2007 between 8.15am and 6.15pm this inspection was the inspectors first visit to the home to complete an inspection. Mrs Cameron the care manager had returned the Annual Quality Assurance Assessment form to the Commission; this was discussed as part of the inspection. Documents, records, reports, were made readily available. Staff and management assisted during the time spent in the home. A tour of the home and sample of facilities were observed. Since the previous inspection Mrs Susan Cameron has been approved as the registered person to operate the home. At the time of this inspection the people who use the service or other professionals had not been formally surveyed for their comments as to how the home operates and meets their needs. A number of the people who use the service were spoken with during the inspection. The staff on duty provided the inspector with positive comments of how the service had moved forward under the management guidance of Mrs Cameron. The majority of the previous requirements had been addressed, there were however two of the major concerns based on the concern for the people who use the service comfort and safety, which had not been addressed. What the service does well: During the inspection the staff on duty for two shifts were observed. The inspector was made to feel welcome upon arrival prior to meeting Mrs Cameron. Staff were seen to assist and escort some of the residents from the dining room. The inspector evidenced breakfast served to people who use the service and chose to come to the dining room later. People who use the service responded in a positive manner to the assistance provided, they were well presented throughout the day. Several of the people who use the service spoke of the satisfaction being at the home, there comments were positive “I am happy here its even better now
Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 6 with my wife being here” “ its good here I enjoy being here” one gentleman with a disability demonstrated his pleasure about the home with his body language, smiles and laughter, later this resident told the inspector he was happy and did nor want to move anywhere. Some of the staff told the inspector that they had experienced a number of positive changes within the home under the management of Mrs Cameron.”its much better here now” The catering staff provided home cooked food, this was evidenced during the inspection. Residents comments about the food were favourable. “I have enjoyed my lunch” “The food is good” The inspector observed one member of the afternoon shift escort a resident to a meeting. From the care plan the resident had limited mobility. The staff escorted and praised the resident for doing well when going to the dining room. From discussions and observations and while having contact with the residents; Mrs Cameron demonstrated her commitment to the home and the care and well being of the people who use the service. What has improved since the last inspection? Since the previous inspection Mrs Cameron has been approved as the registered care manager of Wilbraham House. There had been an improvement in the addressing of requirements. Mrs Cameron and her staff are working together to maintain a homely comfortable establishment the residents can call home. This can only be achieved with support and co-operation of the Directors of the home. A total of twenty-four arm chairs were on order following the audit of furnishings. A new industrial dishwasher was due to be fitted on the 21 May 2007. New coffee tables had been distributed around the large lounge. 21 rolls of carpet had been delivered, three bedrooms had had new carpet fitted. During the inspection the carpet layer came to fit another carpet. He is
Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 7 to return on Saturday 19th May 2007 to re-fit the stair carpet, which at the time of this inspection gave the inspector concerns due to its condition and safety for the people who use the service and the stairs independently. The ground floor toilets referred to in the previous inspection report were to be decorated this week. A new bedside cabinet had been purchased for bedroom 26 completing the refurbishment of the room. The management continued to promote more social activities and interest for people who use the service. What they could do better: There remained certain areas that gave the inspector concerns, the failure of the providers to recognise the importance to act on requirements within the given timescales. The commission had received a letter from one of the directors in response to the previous inspection made by another inspector. While the response in general and without prejudice accepted the time scale for the refurbishment of the bathing facilities was extended from the previous timescale of 30/4/07 The facilities were observed during the day and found to be not acceptable in their decoration and facilities. This requirement will remain to be addressed urgently. The inspector was concerned that the radiator and pipe work outstanding from 1/6/06 and the 30/11/06 with a timescale made for the 30/4/07 had not been completed. There were a number of radiators not covered. The care manager told the inspector that a person was coming to the home on the 17 May 2007 to finish the fitting of the guards. This non compliance leaves people who use the service at risk. Bathrooms remained unchanged, no decoration or upgrading of the areas had commenced. This had been made a requirement in the previous report. The inspector identified in one bathroom ,which according to the manager was not in use; had been used for one resident; toiletries used had been left in the bathroom. Throughout the home the inspector identified areas where cross contamination and infection control had been compromised. Toilet rolls and continence equipment had been left uncovered in the toilet and bathrooms. This practice does not ensure the health and safety of the people who use the service against cross infection.
Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 8 The external area of slabs were evidenced to require attention before residents were encouraged to go out to the garden. The carpet in the large lounge remains badly stained and requires a deep clean or replacement. This should be part of the homes general cleaning process. The shower in the recently registered part of the home was identified not to have a thermostat fitted. The care manager took the appliance out of action and informed the staff and two residents that used it. 16th May2007 contact with the care manager told the inspector she had arranged for an electrician to come out today to view the shower. The inspector had serious concerns in respect of the lack of mandatory training for the staff. While the care manager and deputy have experience in POVA and dementia they are not qualified trainers for other aspects of mandatory training. This must be addressed at the earliest possible time. Only two staff had first aid training. Two had food & hygiene. There must be at least one person on each shift including the night shift with a current first aid qualification. It is important that the staff were made aware that mandatory training was not an option and should attend sessions. There was some urgency for the night staff to be part of a fire drill. Records evidenced that no involvement had taken place since at least 2005. This was discussed and will be addressed by the manager. The care manager is to revisit the Service Users Guide to ensure that it is more user friendly and contains the relevant information Care plans sampled were devoid of any diversity, emotional, social or action to take in the event of any aggression being displayed. The risk assessments were discussed and explored with the care manager, who will revisit them. 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. Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,3,4,were reviewed Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Information provided while updated was incomplete in parts. No person was admitted to the home without a full assessment of his or her needs. EVIDENCE: The Statement of Purpose had been amended to provide the relevant information to enable a member of the public to make and informed choice. The Service Users Guide contained out of date information, the document was unwieldy; consideration should be given to provide it in larger print. The care manager told the inspector that she was at this time also developing a current homes brochure People who use the service should be provided individually with the document.
Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 11 The records accessed at the time of the inspection indicated that no person was admitted to the home without an assessment of their health and personal needs. The care manager is to introduce the practice of confirming the placement by written response, thus complying with the National Care Standards. Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor, Standards 7,8,9,10 were reviewed. This judgement has been made using available evidence including a visit to this service. The samples of care plans were not sufficiently comprehensive to recognise all the care provided. Arrangements were in place for the continued health care needs of the residents. The poor practice of the medication leaves the people who use the service at risk. Staff on duty were observed to be sensitive, supportive and caring. EVIDENCE: Arrangements were in place for the continued health care needs of individuals. This was evidenced from the records and by verbal discussions with the manager. At the time of this inspection two people who use the service were in receipt of care from district nurses.
Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 13 The care plans, while there was an improvement based on information from the previous inspection report and on the evidence seen at the time of this inspection. Areas remain of concern where issues need to be addressed. Three care plans were sampled there was no information of the manner in which residents were offered diversity, emotional support, social development and or spiritual needs. One resident demonstrated her verbal aggression towards another residents. There was no evidence of how this individuals needs were to be met in a situation of confrontation with others.This needs to be addressed in the care plan and how staff can defuse a situation. There was limited focus on risk assessments, the one resident that chooses to part self administer their medication did not have a risk assessment. Residents able to use the stairs require a risk assessment. This was fully discussed with the care manager. This will remain a requirement in this report. The inspector had serious concerns in respect of the medication and the system used. While the staff had received training they were allegedly not told to take the trolley to the place of administration. Medication was found on the floor in the medication room; loose medication was found stuck in the ridge of a packet; tops of boxes had been cut off, this made the medication unidentifiable for the recipient. The home provided a locked box for any controlled drugs this should be secured to the wall, as should the trolley medication is stored in. there were a number of “gaps” in the records. The inspector was unable to evidence if the medication had been taken or not. Medicines received into the home should remain in the original boxes labelled with prescribing details to reduce the risk of mistaken administration. The room used for the storage of medicines was dirty and required cleaning. The manager told the inspector that the home was changing the medication system on the 20 May 2007. Medication training was planned for the 16May this was to include the night staff. During the inspection the inspector observed and heard the staff on duty with the residents. They demonstrated their knowledge of the individuals, assisting and supporting them in their daily routine. One member of staff spoke encouragingly to one resident when mobilising. The staff conveyed a feeling of respect and dignity being afforded to individuals. Residents were well presented throughout the day, it was obvious that for some of the residents this would have been with the assistance of the staff. Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate Standards 12,14,15 were reviewed. This judgement has been made using available evidence including a visit to this service. The social care and activities continued to be developed, to match individuals preferences. Visitors were welcome to visit the home at any time maintaining contact with their relative. The people who use the service were provided with a plain content menu. EVIDENCE: Staffs encourage the residents to be part of any activity within the home; two residents go into the community to the local shops. It is hoped in the summer to encourage residents into the garden to play bowls. One resident has planted two raised boxes with heather and pansies these were outside his bedroom. Staff on the day of the inspection organised a session of Bingo. It was recommended to the care manager that any activity should be recorded
Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 15 collectively at the moment it is recorded in an individuals care plan. The home needs to develop interest/activities to demonstrate how the people with diverse needs are catered for. Every encouragement is made to families and friends to visit. Many of the residents have a close relationship with people in the village making visiting easy. Each quarter the home arranges a high tea with music for residents and families. The meal of the day was Gammon, followed by chocolate sponge and custard. The cook prepares daily a selection of home baked cakes for tea time, which were evidenced during the inspection; home cooked puddings on a daily basis was a commitment to a balanced diet. The menus evidenced that there were no written alternatives to the meal served today. The deputy manager later in the week told the inspector that the cook asked residents preference for the day. Although there was no evidence of any other food being served on the day. A record needs to be maintained of alternatives served. The care manager told the inspector that a new dishwasher was to be delivered on Monday 20 May 07 The temperatures of the fridge/freezers were higher that the expected guidelines while this is recorded on a regular basis it needs to be addressed. One fridge/freezer has a split seal and is a harbinger for germs; a replacement should be purchased to ensure the health of the residents. Both fridge/freezers were in need of cleaning. Food prepared and stored in the freezers were not dated or identified as to the content. This was discussed with the care manager at feedback. This will be a requirement in this report. During the inspection it was evidenced that one person had a vegetarian diet, it was recommended that this person was consulted and a weekly menu prepared based on the likes and dislikes of the person. This will ensure that a balanced non repetitive menu was served. Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate Standards 16 18 were reviewed. This judgement has been made using available evidence including a visit to this service. Recent development to the recruitment practice ensured the safety of people who use the service by robust checking being made prior to employment. EVIDENCE: The commission had not received any form of complaint since the last inspection. The care manager told the inspector there had been no concerns raised with her. It was advised that the complaints procedure was re-hung in the entrance hall ensuring that information was accurate. Staffs via the appropriate training were made aware of the need to protect residents from any form of abuse. Residents spoken with were aware that they could speak to the staff or manager if they had a problem. They also expressed that they felt they would be listened to. The homes recruitment system had been developed further to ensure the safety of people who use the service when employing new staff.
Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor Standards 19 20 21 23 24 25 26 were reviewed. This judgement has been made using available evidence including a visit to this service. The home in areas did not provide a safe, well-maintained environment for the people who use the service. Areas evidenced that people who use the service were not always protected from cross contamination or infection. EVIDENCE: Located opposite the local church, Wilbraham House stands in its own grounds; parking is at the front of the home. On arrival part of the car park had a large area of water, which appeared to be from a blocked drain.
Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 18 There had been a slight improvement in the homes environment following the previous inspection with new carpets being fitted. This continued during the inspection. The safety of the residents was still compromised when radiators and pipe work had not been covered within the timescales of 1.6.06 30.11.06. 22.2.07. The care manger told the inspector that areas not covered had been measured. This practice of non-compliance leaves people who use the service at risk. The planned decoration and refurbishment of the existing part of the home has not taken place the large lounge is extremely tired and dated, not a pleasant environment to relax in. The commission had not received the requested refurbishment and development plan from the providers. The carpet in the larger lounge was badly stained and was in need of replacement. There were some plans to develop this area but no time scale was evident. A number of bathrooms remain unchanged although the care manager told the inspector that one toilet near to the communal area was to be decorated next week. This was only one area, the remaining bathing and toilet areas were poor in decoration with the exception of the newer part of the home. the provision of closed cupboards in the bathrooms/toilets would protect the people who use the service from cross contamination/infection. The shower in the newer part of the home was without a thermostatic control, this was tested by the inspector and found to be a potential hazard for residents. The care manager told the inspector two residents used the shower independently. It was suggested that until checked by a qualified person that it was taken out of use to protect the people who use the service . Following the suggested audit of furniture made by the previous inspector, the manager was expecting 24 new arm chairs next week, new coffee tables had been delivered. A new bedside cabinet had been purchased for the respite room in the newer part of the home to complete the refurbishment of the room. The carpet on the stairs used independently by residents was in a poor condition being thread bare on the treads a potential hazard for residents. This was part of the discussion with the care manager. During the inspection she spoke to the person fitting the carpet who agreed to return on Saturday to fit new carpet on the stairs. 04/06/2007 this was checked with the staff on duty at 7.30 am who confirmed that the carpet had been replaced. Evidenced from the window onto the garden were slabs that will need to be relaid before residents access the garden.
Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 19 One fire door was wedged open and number required re-adjusting to ensure they were effective in the event of a fire. The practice of wedging any fire door should cease it puts people who use the service and the staff at risk. From the sample of the bedroom it was obvious that people who use the service were encourage to personalise their personal space. Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. Standards 27 28 29 30 were reviewed This judgement has been made using available evidence including a visit to this service. The home appeared to have sufficient staff on duty to meet the daily needs of the present people who use the service. to further protect people who use the service an urgency to undertake obligatory staff training was required. EVIDENCE: From discussions with the staff on both shifts during the day it was obvious to the inspector that they were committed to the residents. Staff were responsive to requests made by residents, they had a pleasant approach and they worked as a team to provide a relaxed environment. Staffing levels had been re-arranged to support the night staff; this enabled a relaxed rising time for all the people who use the service. Observed on arrival that not all the residents came down for an early breakfast. Staff training for NVQ in Care level II continued with five more staff registering this week. The home had the projected 50 of staff with the qualification.
Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 21 From the evidence provided by the care manager, Aqua and from discussions with staff there was an urgency for staff to update mandatory training for First Aid, Food Hygiene, Infection Control, Health & Safety Moving & Handling. A letter received from the providers informed the Commission that the care manager and her deputy could provide some of the training. On reflection and discussions it appears that neither person were qualified trainers and as such would not be able to provide the relevant training programme. There should be a least one person on duty at all times including the nights who has a first aid qualification. The local college were due to see the manager next week to arrange training. The care manager has re-structured the recruitment process, ensuring that no person was employed prior to all the required checks were in place. She has developed an interview form. She was to revisit the application form to ensure that the question in respect of any conviction under the “Rehabilitation of Offenders Act” and any offences was on the form. Staff files checked appeared satisfactory, one file contained only one reference following a discussion the manager, who would seek a character reference for the employee due to her circumstances at the time could only provide one reference. Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate Standards 31,33,36,38 were reviewed. This judgement has been made using available evidence including a visit to this service. The home was operated for the benefit of the people who use the service by an experienced staff team. The health and safety and welfare of the people who use the service could be compromised with the need to address the issues of safety and infection and training identified in this report. Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 23 EVIDENCE: The care manager has a number of years experience in the care of older people, at the moment she is completing the Registered Mangers Award, since achieving NVQ level 4 in Care. She had a relaxed style of management and from the time spent in the home she demonstrated her commitment to the residents, staff and improving the environment. The staff spoke highly of her and the changes and support since being at the home. During the inspection staff verbally confirmed that they had commenced receiving supervision to determine their training and development needs. There has been some development in the quality assurance system; the manager to include all the relevant parties will further explore this. The fire records provided indicated that the emergency lighting had not been tested since December 2006. The weekly test of the system was satisfactory. There was a need as a matter of urgency to complete a fire drill for the night staff. Records referred back to 2005 could not evidence any person on the night shift taking part in a drill. This could put people who use the service at risk. It was recommended that any training in house that staff signed personally their attendance and involvement. A record for the chlorination and testing for legionella were current and no concerns were identified, this record was provided on request. Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 24 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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 2 2 X 2 2 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 2 Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP25 Regulation 13 & 23 Requirement Radiators and pipe work must be guarded or have guaranteed low temperatures surfaces. (Previous timescale 1/06/06 & 30/11/06) 30/04/07 Timescale for action 01/06/07 2 OP7 15 3 OP21 13, 16 & 23 All people using the service must have an up to date care, detailed care plan with appropriate risk assessments. This will ensure that they receive the appropriate care and support that meets their needs All bathrooms and wc’s, (with the exception of those located in the new basement conversion), must be cleared of all stored items, including communal toiletries and each area must be redecorated to provide an environment more conducive to promoting a better standard of décor and hygiene. 31/03/07 this will ensure that the people using the service are more protected against the risk of infection and harm
DS0000005035.V338305.R01.S.doc 15/06/07 10/06/07 Wilbraham House Residential Home Version 5.2 Page 26 4 OP9 13 (2) 5 OP15 16 (g)(i) 6 OP38 23 (4)(a)(e) When medication is received and 10/06/07 administered to people using the service it should remain in the box it arrives in, which contains all the relevant information. Medication must be clearly recorded, controlled drugs cupboard and the trolley used must be secured to the wall. This will ensure that all the policies and procedures for the safe administration of medicines are followed. The safety of the people who use the service must be considered at all times. The area where medication is stored should be kept clean and tidy. All people using the service 10/06/07 should receive a balanced diet with daily recorded alternatives. The provider shall provide appropriate kitchen equipment. Food shall be labelled. Equipment shall be maintained in a good hygienic condition This will ensure the health and safety of the residents. To protect the people that use 10/06/07 the service fire doors must not be wedged open. Staff must be training by the means of fire drills on a regular basis Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 27 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 OP33 Good Practice Recommendations The Proprietors should provide the CSCI with a refurbishment/development plan for the Old Vicarage site for the period 2006/07. (Outstanding) 2 3 4 OP15 OP21 OP1 To ensure that the person that uses the service received continuity in his diet a menu to meet his personal needs should be completed. The people using the service shall be protected at all times the staff shall monitor the temperature of the shower after it has been adjusted. The Service User Guide must be updated and made available to all residents. Outstanding 28/04/07 this will ensure that people using the service will be fully aware of the conditions and facilities of the home they live in. To ensure the safety of the people who use the service, prior to any person using the service going into the garden the slabs identified shall be re-laid to protect individuals against a potential fall 5 OP19 Wilbraham House Residential Home DS0000005035.V338305.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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
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