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Inspection on 22/02/07 for Wilbraham House Residential Home

Also see our care home review for Wilbraham House Residential Home for more information

This inspection was carried out on 22nd February 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There was a pleasant and friendly ambience in the home during the inspection visits and residents appeared relaxed. Several observations were made of a variety of staff responding to residents in a caring and competent manner. Several residents commented favourably about the quality and variety of meals and refreshments provided by the home and the Inspector had lunch with residents on the first day of the inspection and was provided with a nutritious and tasty hot meal.

What has improved since the last inspection?

Since taking up her post in September Mrs Cameron has worked well with the staff team to identify and implement a number of improvements, many of which were acknowledged by both residents and staff. The staffing rotas have been amended to provide a more regulated deployment of hours and a better framework for staff handovers, which have been formalised. The Statement of Purpose has been revised and provides comprehensive and up-to-date information. The need for an up-to-date Service User Guide was recognised and a timescale for this was agreed with the manager. Working schedules and daily planners have been implemented to promote better consistency of service delivery and accountability. Pre-admission procedures and assessment of need had been reviewed to ensure a more comprehensive approach and it is also recognised that individual care planning needs to be further developed to better identify and evidence that needs have been appropriately addressed. There has been a change in the provision of dining space, which has been an improvement, as both dining rooms are now within close proximity to the kitchen. This has had an impact on the two sitting areas used by residents and more thought needs to be given to the most suitable use of this space. Furthermore, the possibility of reinstating the kitchen hatch is to be discussed with the Fire Officer, as this would have practical benefits and overcome the issue of staff over accessing the kitchen itself. Social care provision also appears to have improved over recent months. Several residents highlighted this to the Inspector, which was confirmed during subsequent discussion with staff.

What the care home could do better:

Health and safety matters need to be more earnestly addressed by the Responsible Individual and his appointed team. There were many issues of concern identified during this inspection, some of which have been previously identified during inspection and requirements made. The failure of the Responsible Individual to have these matter addressed is a clear breach of the Care Homes Regulations and the CSCI will take legal advice and continue to monitor the home. The full details of these concerns are included in the main body of this inspection report and at the end of the report under Requirements.In addition to the above health and safety matters, this inspection also identified that many parts of the environment are still in need of redecoration. The Inspector had been given assurances that such work, including attention to bathrooms and toilets, would be addressed immediately following the completion of the extension, by the same decorators, but this did not happen. The result is that many parts of the original home, look shabby, with paintwork damaged, carpets badly stained and there is a poor provision of seating, many chairs having been donated second hand to the home. Staff recruitment must also be improved to ensure that comprehensive procedures are followed, including appropriate checks, to safeguard the welfare of vulnerable residents. Evidence was found of staff in post not having had either POVA or CRB checks and this represents a very serious failing of the home to protect its residents. The Inspector was given assurances by Mrs Cameron that staff who have not yet received their checks, only work in the home under supervision and that this will be maintained until their clearance has been confirmed, which had been prioritised.

CARE HOMES FOR OLDER PEOPLE Wilbraham House Residential Home The Old Vicarage Church Street Audley Stoke On Trent Staffordshire ST7 8HL Lead Inspector Norma Welsby Unannounced Key Inspection 22nd February 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wilbraham House Residential Home DS0000005035.V316692.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.V316692.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 *** Post Vacant *** 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.V316692.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 PD over 55 years Date of last inspection 01/11/06 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, 26 residents, including one older person on a short stay, occupied the home. One resident was also in hospital receiving treatment. 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 there was not a registered manager in post, although the home was being managed by Mrs Sue Cameron who had applied to the Commission for Social Care Inspection (CSCI) to be 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 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. Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Key Inspection was carried out by Ms Norma Welsby, Regulatory Inspector, on the 22 and 28 of February 2007. There were some improvements noted since the last inspection, but it was concerning to find that previous requirements, relating to the health and safety of residents, had still not been addressed by the Responsible Individual, despite previous assurances from the Operations Manager. Further matters of concern were also identified during this Key Inspection and are detailed in this report. While the home is without a Registered Manager at present, Mrs Sue Cameron has been appointed as the person in charge and has submitted an application to the Commission for Social Care Inspection, (CSCI), to be approved as the Registered Manager for Wilbraham House. Mrs Cameron commenced employment at Wilbraham House in September 2006 and along with the deputy manager of the home had embarked upon a programme of improvements, which are acknowledged in this report. Throughout the period of this inspection, the inspector received helpful assistance from Mrs Cameron, the staff team as a whole and residents, all of whom made a positive contribution to the findings of this inspection. On the afternoon of the first day of inspection, the Responsible Individual, Mr Sukhinder Singh Kandola, visited the home and discussions took place in respect of the matters of concern relating to health and safety. It was agreed that Mr Kandola would consult with his partner and communicate with the Inspector during the subsequent planned visit to the home on the 28th of February 2007. What the service does well: There was a pleasant and friendly ambience in the home during the inspection visits and residents appeared relaxed. Several observations were made of a variety of staff responding to residents in a caring and competent manner. Several residents commented favourably about the quality and variety of meals and refreshments provided by the home and the Inspector had lunch with residents on the first day of the inspection and was provided with a nutritious and tasty hot meal. Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Health and safety matters need to be more earnestly addressed by the Responsible Individual and his appointed team. There were many issues of concern identified during this inspection, some of which have been previously identified during inspection and requirements made. The failure of the Responsible Individual to have these matter addressed is a clear breach of the Care Homes Regulations and the CSCI will take legal advice and continue to monitor the home. The full details of these concerns are included in the main body of this inspection report and at the end of the report under Requirements. Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 Page 7 In addition to the above health and safety matters, this inspection also identified that many parts of the environment are still in need of redecoration. The Inspector had been given assurances that such work, including attention to bathrooms and toilets, would be addressed immediately following the completion of the extension, by the same decorators, but this did not happen. The result is that many parts of the original home, look shabby, with paintwork damaged, carpets badly stained and there is a poor provision of seating, many chairs having been donated second hand to the home. Staff recruitment must also be improved to ensure that comprehensive procedures are followed, including appropriate checks, to safeguard the welfare of vulnerable residents. Evidence was found of staff in post not having had either POVA or CRB checks and this represents a very serious failing of the home to protect its residents. The Inspector was given assurances by Mrs Cameron that staff who have not yet received their checks, only work in the home under supervision and that this will be maintained until their clearance has been confirmed, which had been prioritised. 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.V316692.R01.S.doc Version 5.2 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 Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, & 3. Standard 6 is not applicable at the home does not provide intermediate care. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose has recently been amended, but there is a need to update the Service User Guide. Contracts/statement of terms and conditions are in place. The needs of prospective residents are assessed by the senior staff prior to admission to the home. EVIDENCE: During this Key Inspection the Inspector was given a copy of the updated Statement of Purpose. This was examined and found to be satisfactory. It was confirmed that the Service User Guide still needed to be updated and a date to complete this task was agreed with Mrs Cameron. Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 Page 10 A copy of the home’s contract/terms and conditions was also seen during this inspection and this was satisfactory, with the exception of needing to include the details/number of the bedroom to be occupied by the resident. The manager and deputy manager take the lead role in the assessment of prospective residents. The Inspector was assured that the home undertakes its own assessment and recently revised paperwork used for this purpose was shown to the Inspector. The Inspector was satisfied that that the preadmission and assessment procedures being carried out by the home were based on good practice. The home’s registration categories were discussed and clarified. It was ascertained that the needs of one gentleman is not compatible with the home’s categories of registration and the Responsible Individual must apply for a variation of category as a matter of urgency. Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning processes within the home provided staff with insufficient information to meet resident’s needs satisfactorily and it was agreed that these should be developed further. Health care needs were met and comments received from residents confirmed that they were satisfied with the standard of personal care. Medication records and procedures were examined and were satisfactory. Residents were treated with respect and their right to privacy upheld but environmental shortfalls negate from the overall outcome. EVIDENCE: A sample of care plans were examined and following discussions with the manager and deputy manager of the home, it was acknowledged that these Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 Page 12 could be further improved. Ways to achieve improvements were discussed and it was evident to the Inspector that senior staff have a commitment to improving care planning at Wilbraham House. It is important that residents are involved in their care plan and evidence of this will be examined in future inspections. A wide variety of health care professionals are involved at Wilbraham House and it was apparent that the home was involved in a multi disciplinary approach to meeting residents’ needs. There have been some issues of hygiene, but it was felt that these were being better managed and no area of specific concern was identified during this inspection. Another prevailing issue has been the concern of some health care professionals that the home continues to care for some residents after their needs have moved beyond residential to nursing care needs. This matter was fully discussed with the manager and deputy and the complexities of such situations acknowledged. The Inspector advised that it was absolutely crucial that the home maintain an open dialogue with the resident, relatives and health care professionals so that a shared decision could be made as to whether an individual should be referred to social services for a re-assessment of their needs. The management and administration of medication was satisfactory. Named staff are responsible for administering medication, most of whom have had previous extensive training and further training was planned. Only one resident self-administers part of his prescription and the Inspector was told that a lockable facility has been provided. Medication stock, storage and administration records were examined and found to be satisfactory. Observations of staff conduct throughout the period of this inspection conveyed a feeling of respect and dignity being afforded to residents. Residents were very presentable, with obvious attention given to the ladies hair and dress. Male residents were also smart and were given assistance with their appearance if needed and had regular access to a barber. By contrast, however, attention to detail in respect of the environment, particularly bathrooms and toilets remains neglected. Many of these areas, routinely used by residents, are shabby and poorly presented. For example the WC adjacent to the staircase is of a very poor standard and it was freely admitted by staff during the inspection that they would not like to have to use it. These poor standards, combined with the unsuitable and poor provision of chairs in the lounge areas, negates from the overall sense of respect and dignity otherwise afforded to residents. Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Wilbraham House provides a good programme of activities and entertainment. Encouragement is given to maintain links with the local community and with friends and family. Without exception all residents who were consulted were very complimentary about the good quality of food that was consistently served by the home. EVIDENCE: Several residents told the Inspector that the provision of social care had improved over recent months. This was confirmed by staff and also through discussions with Mrs Cameron who stressed that she felt it was one of her priorities to provide a better range and consistency of social care opportunities. Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 Page 14 Every encouragement is given to residents’ family and friends to visit the home and maintain links with their older relative. During this inspection four visitors were consulted and for the most part their comments were positive. However they did raise with the Inspector that when they visited there was not enough chairs for them to sit down with their relative and each time they had to find chairs from other parts of the home. This comment was conveyed to Mrs Cameron who agreed to address the matter. Links are also maintained with the local community – residents having the opportunity to visit the village shops and other local facilities and this is especially important, as many residents have strong ties with the Audley. There was evidence of residents being consulted and encouraged to make choices and maintain control over their daily lives. Many residents confirmed this to the Inspector and observations were also made of staff consulting with individuals and promoting personal decision-making. On the first day of this inspection, the Inspector had lunch with a group of residents in the newly created dining room. This room makes a very pleasant dining room and residents were very positive about this recent change. A tasty hot lunch was provided and staff were observed to consult with residents and to provide discrete encouragement and assistance. Without exception, all of the residents consulted, (approximately 40 ), were very complimentary about the provision of meals and refreshments. Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 Page 15 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): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does have an established complaints procedure in place. Poor recruitment procedures do not protect vulnerable residents and all staff were in need of refresher training in respect of identification of abuse and the correct vulnerable adult procedures to follow. EVIDENCE: Wilbraham House had a complaints procedure in place and several residents confirmed that they were aware of their right to complain and to whom they would raise their concerns. It was also ascertained that senior staff were ‘approachable’ and there was a sense of confidence that matters would be addressed appropriately. The home had not received any complaints since the last inspection, nor had any complaints been sent to the Commission for Social Care Inspection. It was very disappointing and concerning to find that the home’s staff recruitment procedure had not been improved, despite having been raised during previous inspections of the home - (Requirements made in the Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 Page 16 inspections of 23/03/06 and 1/11/06). It was found that at least two staff had been appointed and had started working in the home without their POVA and CRB checks being in place. It was also found that for at least two existing staff, there was no evidence that CRB checks had been carried out, despite previous assurances to the contrary. The seriousness of this finding was discussed with Mrs Cameron who confirmed to the Inspector that each of these staff were working under supervision of a senior member of staff and that it was her priority to have these checks in place as soon as possible. A requirement was made about this finding. It was also identified that all staff should have refresher training in the identification of abuse and the correct vulnerable adult procedures that should be followed. Wilbraham House Residential Home DS0000005035.V316692.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): 19 & 25 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Wilbraham House does not provide a safe, well-maintained and comfortable environment. Identified concerns are not acted upon in a timely manner and this means that the outcome for this group of standards has major shortfalls. EVIDENCE: During this Key Inspection the Inspector toured the home and found many areas of concern, some of which were outstanding requirements or recommendations from the previous inspection. There had been one improvement of note made since the last inspection and that was the change of use of the middle lounge, which was often over- crowded, into a dining Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 Page 18 room. Many residents commented positively about this improvement and staff were also of the opinion that this change had been positive. Unfortunately, the planned redecoration/refurbishment of the original environment, that was supposed to take place immediately following the completion of the extension, had not been carried out and the consequence has been a sustained deterioration in many areas, which are detailed below as requirements and recommendations. The following requirements were made: Radiators and pipe work must be guarded or have guaranteed low temperatures surfaces. (Previous timescale 1/06/06 & 30/11/06) (The Responsible Individual Mr Kandola emailed the Inspector on the 28th of February 2007, confirming in writing that this outstanding requirement would be fully complied with by the end of April 2007.) All care call cords and electrical cables, (mainly from table lamps), must be made safe so that residents are not at risk from tripping. It may be necessary to provide additional sockets in a better location to ensure that residents have appropriate access. There must be a full audit of all seating in communal areas to ensure that it is of good quality and suitable for a range of individual needs and that there is ample seating to cater for the registered capacity of the home, which is 33. Consideration must also be given to provision of additional seating for visitors to the home. All aids and equipment in the home must be suitable for use: they must be serviced regularly, assessed that they meet health and safety standards and, where necessary, replaced to ensure assessed needs are met appropriately. (Two bath chairs were observed to be rusting under the chair and even the new one in the extension showed early signs of rusting. There were no records available to evidence that either of the original two bath aids had been serviced and staff could not recall any servicing having taken place) Of the four bathrooms, only two are in use to bathe or shower, and action must be taken to provide additional, suitably adapted facilities to meet residents’ needs. The broken and unsecured freestanding wardrobe in the first floor bathroom/wc must be removed as it is unsafe and its use as an open shelved linen store unsuitable. 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. Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 Page 19 The Inspector also discussed the following recommendations: The fire officer should be consulted about reintroducing the kitchen/dinerserving hatch, which would provide a useful facility and help reduce congestion along the adjacent corridor. (Outstanding) The Proprietors should provide the CSCI with a refurbishment/development plan for the Old Vicarage site for the period 2006/07. (Outstanding) The practice of storing items on toilet pedestal lids should cease forthwith, and ensure toilet roll holders are maintained. (Outstanding) There should be a review of the current usage of the two lounges to ensure that the needs of residents are met appropriately, that any risks are addressed and in order to provide a more comfortable and homely environment. Wilbraham House Residential Home DS0000005035.V316692.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 adequate. This judgement has been made using available evidence including a visit to this service. Wilbraham House had sufficient staff with the skills mix to meet the needs of residents. NVQ has progressed well but a more sustained programme of mandatory training must be established. Robust recruitment procedures were not always in place, including POVA First and CRB checks. EVIDENCE: Staffing levels were found to be satisfactory. Staff rotas have been revised by Mrs Cameron and provide a more regulated deployment of hours and a better framework for staff handovers, which have been formalised. Work schedules and daily planners have also been introduced to provide a better consistency of service and accountability. Observations of staff throughout the period of this inspection conveyed a positive impression. Consultation with several staff also confirmed that there was a commitment to providing a good quality service and a recognition of an holistic approach to meeting the needs of the elderly residents. Nearly 50 of staff now have NVQ level 2 or above. However it was recognised that a programme of mandatory training should be produced to Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 Page 21 ensure all staff have refresher training, as training in some key areas appears to have lapsed. As detailed under Complaints and Protection, the home does not have robust staff recruitment procedures in place and this must be addressed as a matter of the highest priority. Wilbraham House Residential Home DS0000005035.V316692.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): 31, 32,33,35 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. At the time of this key inspection Wilbraham House did not have a registered manager in post, although an appointment had been made and an application submitted to the CSCI. There were substantial failings identified on the part of the Responsible Individual to comply with previously identified requirements and in this respect the health, safety and welfare of residents was not adequately promoted and protected. EVIDENCE: Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 Page 23 While the home was without a Registered Manager, Mrs Sue Cameron had been appointed as the person in charge and had submitted an application to the Commission for Social Care Inspection, (CSCI), to be approved as the Registered Manager for Wilbraham House. Mrs Cameron commenced employment at Wilbraham House in September 2006 and along with the deputy manager of the home had embarked upon a programme of improvements, which are acknowledged in this report. Mrs Cameron had achieved NVQ level 4 and was intending to undertake the Registered Managers Award. An open and easy ethos had been established and all staff, including the deputy manager, were complimentary about the Mrs Cameron’s management style. It was advised that regular management meetings are held with the Responsible Individual, Mr Kandola and the Operations Manager, Mr Bobby Dhadda. However the failure of the Responsible Individual to ensure compliance with identified requirements is a matter of concern and which has left the home in a position of non-compliance with the Care Homes Regulations. During this key inspection, the Inspector found several areas of concern that presented a risk to the health, safety and welfare of residents. Six requirements were made pertaining to the physical environment and detailed under the set of standards entitled Environment and also in the Requirements at the conclusion of this report. A further requirement has been made about the need for robust recruitment procedures, under Complaints and Protection and two further requirements are detailed below: All incidents occurring in the home that affect the welfare of residents as detailed under Regulation 37, must be notified in writing to the Commission for Social Care Inspection. The hot water boiler used in the kitchen must be relocated to a more suitable and safe place. A recommendation was also made in respect of the home’s quality assurance, namely that consideration should be given to ways of developing quality assurance systems in the home to inform the direction of good practice and satisfactory standards in the future. Records pertaining to the management of residents’ finances were also examined and found to be satisfactory. Wilbraham House Residential Home DS0000005035.V316692.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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 x X X X X 1 1 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 X X 1 Wilbraham House Residential Home DS0000005035.V316692.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) You must demonstrate robust recruitment, application and interview procedures within the home. (Previous timescale 1/04/06 & 30/11/06) All care call cords and electrical cables, (mainly from table lamps), must be made safe so that residents are not at risk from tripping. It may be necessary to provide additional sockets in a better location to ensure that residents have appropriate access. There must be a full audit of all seating in communal areas to ensure that it is of good quality and suitable for a range of DS0000005035.V316692.R01.S.doc Timescale for action 30/04/07 2. OP29 19 Sch 2 (5) 28/02/07 3. OP19 13 & 23 07/03/07 4 OP20 13 & 23 31/03/07 Wilbraham House Residential Home Version 5.2 Page 26 5 OP22 13, 16 & 23 6 OP21 13 & 23 7 OP21 13 & 23 8 OP21 13, 16 & 23 9 OP38 37 10 11 OP38 OP1 23 5 individual needs and that there is ample seating to cater for the registered capacity of the home, which is 33. Consideration must also be given to provision of additional seating for visitors to the home. All aids and equipment in the home must be suitable for use: they must be serviced regularly, assessed that they meet health and safety standards and, where necessary, replaced to ensure assessed needs are met appropriately. Of the four bathrooms, only two are in use to bathe or shower, and action must be taken to provide additional, suitably adapted facilities to meet residents’ needs. The broken and unsecured freestanding wardrobe in the first floor bathroom/wc must be removed as it is unsafe and its use as an open shelved linen store unsuitable. 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. All incidents occurring in the home that affect the welfare of residents as detailed under Regulation 37, must be notified in writing to the Commission for Social Care Inspection. The hot water boiler used in the kitchen must be relocated to a more suitable and safe place. The Service User Guide must be updated and made available to DS0000005035.V316692.R01.S.doc 31/03/07 30/04/07 07/03/07 31/03/07 28/02/07 07/03/07 28/04/07 Page 27 Wilbraham House Residential Home Version 5.2 12 OP2 5 all residents. The details/number of the bedroom to be occupied must be included in the contract. 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to c onsider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations The fire officer should be consulted about reintroducing the kitchen/diner-serving hatch, which would provide a useful facility and help reduce congestion along the adjacent corridor. (Outstanding) 2 OP33 The Proprietors should provide the CSCI with a refurbishment/development plan for the Old Vicarage site for the period 2006/07. (Outstanding) 3 OP38 The practice of storing items on toilet pedestal lids should cease forthwith, and ensure toilet roll holders are maintained. (Outstanding) 4 OP27 There should be adequate hours of maintenance/handy man or demonstration of alternative satisfactory arrangements. (Outstanding) 5 OP20 There should be a review of the current usage of the two lounges to ensure that the needs of residents are met appropriately, that any risks are addressed and in order to provide a more comfortable and homely environment, Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 Page 28 6 7 OP18 OP30 All staff should receive refresher training in Staffordshire County Council’s Vulnerable Adults Procedure. A programme of mandatory training should be produced to ensure all staff have refresher training and this should be available for inspection by the CSCI Consideration should be given to ways of developing quality assurance systems in the home to inform the direction of good practice in the future. Care plans should be developed further to ensure that staff have adequate information to meet assessed individual needs. 8 9 OP33 OP7 Wilbraham House Residential Home DS0000005035.V316692.R01.S.doc Version 5.2 Page 29 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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