Inspection on 23/03/06 for Wilbraham House Residential Home

This inspection was carried out on 23rd March 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wilbraham House Residential Home 23/01/09

Wilbraham House Residential Home 25/01/08

Wilbraham House Residential Home 15/05/07

Wilbraham House Residential Home 22/02/07

Wilbraham House Residential Home 29/06/05

Wilbraham House Residential Home 11/02/05

Wilbraham House Residential Home 05/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Wilbraham House Residential Home The Old Vicarage Church Street Audley Stoke On Trent Staffordshire ST7 8HL Lead Inspector Keith Jones Unannounced Inspection 23 March 2006 10:00 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.V287028.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. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 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 Elaine Bailey Care Home 27 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (27), of places Physical disability over 65 years of age (6) Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 PD over 55 years Date of last inspection 29/06/05 Brief Description of the Service: Wilbraham House is a privately owned residential care home, registered to care for up to 27 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 Announced Inspection, 23 residents, including two older people on short stay, occupied the home. Two residents were 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. The Registered Manager is Mrs Elaine Bailey, who has been in post for three years. There are plans to convert the basement to provide additional bedrooms and other facilities and an application to increase the registered numbers, possibly to 33, has recently been submitted. The inspector was able to examine details of the plans on site during this inspection and gave some initial feedback. 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. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over one day, by one inspector with senior care staff, in a professional, frank and open manner. The last inspection report was discussed with the acting Operations Manager, and it was noted that all outstanding recommendations had been dealt with satisfactorily. The Care Manager attended for a short time although on sick leave at the time. On the day of inspection there were 24 service users in residence. A tour of the Home allowed free and open access to all areas for inspection. The opportunity was taken to speak with a number of service users and members of staff. Service users and staff took an active role in the inspection process and contributed to the subsequent report. Throughout the entire inspection a sense of homeliness and familiar confidence pervaded into all aspects of daily activity expressed by those people met. Some of the previous requirements and recommendations have not as yet been attended to satisfactorily, which needs the immediate attention of the Registered Provider. The general quality of the environment was homely and comfortable, yet still requiring remedial action to compliment the completion of the extension work. It is expected that commissioning of the extension will take place in May 2006. The Inspector was satisfied that existing care and service arrangements to accommodate the building work were not adversely affected. A sample review of the administrative arrangements and servicing records confirmed solid practice and effective management. A full verbal report was offered at the end of the inspection to the assistant deputy care manager. The inspector thanked all concerned for their contribution to a pleasing and constructive inspection. What the service does well: Wilbraham House offers a good, solid standard of care and service, is well organised, with a committed care management team, that have managed to resolve the organisational problems highlighted at the last inspection. Positive action goes into involving the residents and their families in the process of care, ensuring a highly personal approach to meeting individual needs. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 6 Assessment procedures and care planning is of a good standard, offering detailed information on each resident’s progress in the meeting of objectives. The housekeeping and support services all contribute to the team approach, and are recognised by the management for their efforts. Wilbraham House is located in a very close-knit village community and as such provides a valuable resource to many local elderly people who wish to remain in the village. Overall the attitude in meeting caring and organisational demands is highly commendable, with forward thinking, planning and application contributing to an excellent service. What has improved since the last inspection? What they could do better: 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. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Wilbraham House ensures that prospective residents have the necessary information to enable an informed choice to be made. Aims and objectives, terms and conditions are clearly presented in a way to facilitate easy understanding of services and standards of care. The assistant deputy care manager assured that the admission process is a reflection of a joint understanding that residents are aware, and that staff are able to meet expectations to realise a comfortable transition. A review of the Statement of Purpose, Service User Guide and Contract will be undertaken to accommodate changing environmental and organisational demands resulting from the extension work. EVIDENCE: The Statement of Purpose and guidelines reflect an expression of philosophy, and have been well established in representing the foundation on which the home operates upon. It presents an excellent description of the home’s aims Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 9 and objectives, philosophy of care and terms and conditions. All the requirements prescribed in Schedule 1 are addressed. The care management adheres to an admission policy of personal supervision of the pre-admission assessment. Case tracking demonstrated the presentation of a highly personal approach to prospective residents and their relatives on pre-admission. A detailed assessment was examined and found to collect a full profile of physical and psychological needs, as well as social, cultural and environmental circumstances. Case tracking of four service users care records showed that an appraisal is made, and discussed, to ensure the home can satisfactorily meet those needs. Case tracking and discussion with service users confirmed that this standard continues to be well met. Following an assessment the senior carer assessor determines the suitability of the application in view of the facilities available, and at the capacity of the home, to manage the individual and any special needs. Likewise the applicants are informed of those facilities and are encouraged to seek clarification concerning the general and specific services available for the prospective service user. Case tracking confirmed that a valuable exchange between service users and assessor took place and resources made available. These resources were seen to be an appraisal of staffing skills, equipment and general environment. Prospective service users and their relatives are able to visit and assess the quality, facilities and suitability of Wilbraham House at any reasonable time, to meet with staff and management. At all times relatives are involved throughout the process. The home does not admit emergencies, or provide intermediate care. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 10 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 and 10 Overall the care assessment and planning system is an organised, yet personalised process offering meaningful and valid documentation of care administered. A broad vision of needs is addressed through the care planning process, attempting to meet personal and health needs. Ownership of assessments through dating and signature would enhance the meaningfulness of the process. The provision of a secure and safe medicines administration is managed efficiently. A secure storage and recording system is advised to manage controlled drugs. Staff were seen to demonstrate a personal empathy with residents through a respectful, yet friendly discourse. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 11 EVIDENCE: Four service users were case tracked, with a full examination of care records, health records including professional and general practitioners visits, risk assessments, dependency charts, records of reviews and action plans. The pre-admission assessment represented the foundation for a well-considered and detailed care planning process, although assessment would be more meaningful with a signed and dated ownership of the procedure. A profile of the service user’s social, physical and emotional status offered an individual plan of care, based upon daily living reviewed monthly. Evidence of health care professional visits showed an attentive awareness to service user’s needs. Daily reports were acknowledged as a valuable process that have been standardised for all service users. There was evidence of consultations from medical specialists and other professional support services. There was evidence that administration of drugs procedures were seen to be up to date and accurate. There were no residents self-medicating at the time of inspection. The clinical room is very small and in close proximity to central activity of the Home. There is a Controlled Medicines cupboard, which needs to be secured. It was noted there no resident was receiving Controlled drugs at that time. Examination of the accident records showed consistency in the completion of the record, with clear descriptions of injuries and interventions made. The spiritual orientation of each service user is recognised within care records. The prevailing personable atmosphere in the home is extended to encompass the needs of relatives and friends during difficult times. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 12 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 aims to provide a life style for service users, which enriches their social, cultural, religious and recreational interests and needs. The home operating an established open visiting policy, being well located in the village of Audley, providing excellent access to a wide range of local facilities. The activity assistant continues to provide a good range of social activities, including one to one and small group sessions, which include reminiscence, music sessions, games and quizzes. The high standards of catering at Wilbraham House offers an excellent service, to which all service users spoken to were highly complimentary. There is a need to improve the organisation and administrative arrangements regarding catering. Dining room facilities are difficult due to the split areas, and the lack of a serving hatch from the kitchen. On completion of the building the Operations Manager will be addressing this matter to accommodate the increased numbers of residents. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 13 EVIDENCE: Discussions with service users and staff clearly identified a relaxed and informal atmosphere in which the service user’s needs were paramount. A routine exists to establish a framework for managing the home, not as a yardstick for service users to comply with. Several residents expressed their appreciation for the freedom they enjoyed, with the security that there are familiar events to the day they could relate to. The Home has the services of an activity coordinator for six hours a week, consideration should be given to reviewing these hour with the increase in residents, and complimenting the importance that the Registered managers have for the socialisation aspects of care. Those service users’ rooms inspected showed a strong influence of personalisation in the inclusion of belongings, some furniture and general décor. The good standards of catering at Wilbraham House offered an excellent service, to which all service users spoken to were highly complimentary of all aspects of quality. A menu on a four weekly cycle offered a wholesome, varied and excellent choice. The catering assistant demonstrated her awareness of individual resident’s needs and choices. Individual preferences were recorded in assessment and conveyed to cook, who met with, and discussed their requirements. It was confirmed that the cook knew each resident, and some of the relatives. An excellent lunch was served during inspection, with choices available, served in two well-furnished and clean dining rooms. Staff were seen to offer discreet assistance to those who required it. The choice of dining room, lounge or bedroom was at the discretion of service users. The kitchen was seen to be well equipped, although poor in ventilation. Records for food and fried/freezer temperatures were not up to date. The cleaning schedule had long gaps in the record of items and areas cleaned. The flooring in the kitchen has right angled joints to fixtures, resulting in the collection of debris and dirt. Care staff were seen to have free, unchallenged access to the kitchen, often coming from direct personal care events. These matters are to be addressed for immediate action. COSHH signs and notices were in evidence with cleaning chemicals secure, appropriate and under control. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 14 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 and 18 The home had a meaningful complaints policy, clearly identifying the CSCI as a resource to approach with a complaint or grievance. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. Service users’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. EVIDENCE: The complaints policy was seen and records examined. There were few minor complaints assessed, all dealt with at the source. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. Case tracking confirmed the effectiveness of a care manager and staff sensitive to service users needs and readiness to test the robustness of their information and report structures. As part of the process of encouraging self-determination a policy exists to be able to offer advocacy services should they be required. Family involvement has been the usual means of representation in the past. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 15 Residents’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place i.e. the complaints procedure. This process was evidenced on examination, and case tracking as previously reported upon. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 16 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): 19,20,21,22,23,24,25 and 26 The home is well appointed to meet the needs of an elderly population of service users in providing a safe and comfortable environment. Bedrooms were well maintained to meet service user’s personal preferences; the outcome is a comfortable and familiar private domain that reflects the service user’s preferences. Work is under way on extending the Home to 33 beds. The care manager and staff have managed to contain disturbance to a minimum. The work is hoped to be completed by the end of May 2006. There are plans for an extensive redecoration and refurbishment throughout on building completion. Individual rooms are presented as highly personalised and inviting individual domains. The Home continues to present a clean and pleasant, generally odour-free atmosphere, much to the credit of staff. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 17 EVIDENCE: The location of Wilbraham House is conducive for a care home, situated in a village setting with good access to road links, and a short drive to Newcastle. The Home provides a safe, comfortable, friendly and homely environment. There were 24 service users at the time of inspection. External access is satisfactory for visitors, although building work is restrictive. Service users take advantage of attractive gardens and grounds; pathways were safe and recently attended to. Building work is evident but represent no overt risk to service users. CSCI will be involved at various stages during the work. The intended garden area was being prepared to provide ambitious facilities, i.e. bowling and putting. However consideration should be given to the pathways leading to the garden areas and surrounding the perimeter of the Home. There are few contingencies to accommodate wheelchair users, noting that the inclines are problematic to ramps. During this unannounced inspection, the Inspector carried out a review of the physical environment of Wilbraham House. Internal access was facilitated with adequate fittings of hand and grab rails, in well-lit and airy corridors. Wheelchair access was satisfactory throughout all areas of the home, although the storage room requires securing. Bedrooms were well maintained to meet service user’s personal preferences. It was evident that there were examples of minor maintenance to décor that was awaiting a full redecoration following the extension work. There is a programme of routine maintenance in operation, with the home having a handyman contracted to work 6 hours each week. Each of the communal areas was in use and was comfortable and attractive in appearance. Health and safety shortfalls were identified, including the completion of the programme to guard all radiators. While some radiators have been guarded, those fitted with wooden guards are very attractive and suitable, many others, particularly in bedrooms have been fitted with a wired frame, many being too small, and have been left unsecured. The Operations Manager has not followed through the recommendation for ensuring the safety by persisting in using the totally inadequate wire guards and not accommodating safety features for radiators in the extended area. The timescale for the completion of this programme is to be notified to the Inspector in the action plan to be forwarded to the CSCI, as a point of such importance. It is expected that a conclusion to this issue be reached by June 2006. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 18 A sample of bedrooms was viewed during this inspection and each of these was found to be generally satisfactory. Several rooms had wardrobes that had not been secured. One bedroom was considered to have an unacceptable malodour, which needs immediate and determined action. Bathrooms and toilets were also inspected. These remain unattractive and bland in appearance and some were congested with the storage of inappropriate items. One bathroom was not in use, had a hoist that had no service record. The senior carer indicated that this room is planned for conversion to a shower room. One in-use toilet had a very poor split flooring cover. There was a persistent use of storing items on the cistern lids of toilets, considered to be a cross-infection potential in communal toilets. The Inspector advised that the improvement in the appearance of bathrooms and toilets remained a requirement of this inspection and should be included in the previous mentioned Inspection action plan, to be submitted to the CSCI. The laundry area was inspected and found to be organised and well equipped. The area would benefit from an enhanced display of COSHH notices to facilitate a safer environment. The Inspector found the home to be generally clean and well presented during this inspection. However, it was ascertained that the requirement made to review domestic hours remain unchanged at just 17.5 hours each week. This provides 3.5 hours from Monday to Friday, with no provision made for weekend. Given the size and layout of this home, the Inspector feels that in order to maintain a clean, pleasant and hygienic environment and without impinging upon the role of the care staff, the arrangements for domestic cover must be increased to a minimum of 30 hours a week, to allow for four hours a day, raising to a minimum of 40 hours a week on completion of the extension. This was discussed during the inspection and again should be detailed in the action plan. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 19 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 and 30 The overall staffing coverage manages to maintain the expected levels each shift that was inspected, over a three-week period. Discussions with residents and visitors to the home also conveyed a very positive impression of staff conduct. However there is reliance upon care staff working in the laundry area to cover for sickness, holidays and days off of an inadequate domestic coverage. The procedures for recruiting and appointing staff were seen to be inconsistent with various stages of the process not completed, in studying several staff files. Staff training was discussed and was found to need a review of the arrangements in regular training and supervision. EVIDENCE: There were 24 service users in the home on the day of the inspection. Offduties for week commencing 13/03/06 through to 31/03/06 were provided and examined; staffing levels were seen to be satisfactory. The daily care staffing rota showed adequate balance between skills, experience and numbers to provide a good standard of care. Discussions with staff also confirmed their commitment to providing a quality service and their awareness of the principles of good practice. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 20 The staffing establishments were examined and found to be satisfactory in meeting the staffing notice. An average coverage was seen to be: a.m – 1 Senior 4 carers p.m – 1 Senior 2/3 carers N.d - 1 Senior 1 carer Observations of staff on duty conveyed a very positive impression of their competence and care of the residents of Wilbraham House. The home now has a much-improved staffing structure, providing a manager or senior carer on duty on each shift. Domestic/laundry staffing levels were inadequate; staff spoken to were seen to be resigned in having to undertake housekeeping tasks at the expense of care time. However those spoken to were confident, cheerful, experienced and competent in their duties. The senior carer informed the inspector that there are 28 hours catering staff, 39 hours cook, a part time gardener/ maintenance man working six hours a week, and an entertainment coordinator working six hours variable a week. The provision of 17.5 hours a week domestic cover is inadequate to maintain a satisfactory standard of cleanliness. For a 27-bedded residential unit there should be a minimum of 30 hours deployed to ensure four hours a day coverage, including leave and absence. This target should be adjusted accordingly to meet the increased demands of a 33-bedded unit. There should be consideration given to deploying adequate laundry staff to meet a daily need of a high proportion of incontinent residents, and that there are two residents with MRSA at the time of inspection. Several staff files were examined which showed an inconsistency of application of procedure in appointing staff. The procedures for recruiting and appointing staff were seen to be inconsistent with various stages of the process not completed. Several staff had insufficient evidence of clearance with references, application forms, and contracts. The care management is advised to review the procedures of appointing and maintaining staff. Staff training was discussed and was found to need a review of the arrangements in regular training and supervision. Induction was seen to be spasmodic and inconsistent, training records identified the lack of a training programme to meet compulsory requirements for fire safety, health and safety, and hygiene issues. There was no evidence to show that a formal supervision process is in use, although the deputy care manager emphasised the heavy commitment made by senior staff in offering on-duty practical supervision. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 21 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): 31,32,3,34,35,36,37 and 38 The Registered Manager of Wilbraham House is Mrs Elaine Bailey, who is a qualified nurse with many years of experience, having completed the Registered Managers Award. The Registered Proprietors are Mr Pargan Dhadda and Mr Sukhinder Singh Kandola, who purchased the home in October 2001. Mr Kandola is the Responsible Individual for the home. The company Wilbraham Limited employ Mr Bobby Dhadda as the Operations Manager. The Inspector noted the improvement and willing acceptance of roles and relationships that now prevail since the last inspection. Policies are meaningful, with exception to the specific guarding of radiators, are supported with up to date procedures and skilled application of good practice. Each presents a safe and secure environment in protection of rights, interests, health and safety of the residents. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 22 EVIDENCE: Following discussions on the roles of managers the deputy care manager expressed her confidence in the cascade effect throughout the Home. The Inspector witnessed a confidence apparent in the interaction of staff and the Home’s management, that demonstrated a positive relationship that pervades throughout the Home. This open style of management, even though the Care Manager was off sick at the time, was mentioned by several service users, which provided a source of trust and mutual respect. Quality assurance complements this arrangement with a high profile involvement of the Operations Manager, Care Manager/s and Providers on a daily basis. The service users were made aware of the CSCI inspection and several asked to speak with the inspector, showing off their rooms and discussing their position. Each resident has a personal file containing personal and clinical/social information. Several files inspected evidenced a satisfactory standard of maintenance and security of these files. A sample of administrative, maintenance and care records were examined and found to offer an accurate reflection of a service committed to providing a safe and comfortable environment. Servicing records of essential equipment were examined including hoists, and gas maintenance, call alarms and personal electrical PAT testing. Staff training programmes require reorganising to demonstrate that relevant aspects of Health and Safety, infection control, moving and handling and fire training were recorded. All accidents and incidents were recorded for staff and service users, including provisions for Riddor should the need arise. The administration and management of the home is sensitive to the needs of service users. Service users benefited from competent and accountable management. Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 23 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 X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 2 3 3 3 3 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 2 2 2 Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 24 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 Timescale for action 01/06/06 2 OP27 18 & 19 3 OP32 12 (1)(2)(3) (4)(5) 19 Sch 2 (5) 16 2 (g) Radiators and pipe work must be guarded or have guaranteed low temperatures surfaces. THIS IS AN OUTSTANDING REQUIREMENT. All staffing levels must be kept 01/06/06 under constant review to ensure the changing needs of residents are met and that good standards of hygiene and cleanliness are maintained throughout the environment. THIS IS AN OUTSTANDING REQUIREMENT. You must ensure all previous 01/04/06 outstanding requirements are fully met. You must demonstrate robust recruitment, application and interview procedures within the home That a schedule of cleaning and fridge/freezer temperature recordings be established. 01/04/06 4 OP29 5 OP38 01/04/06 Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP19 OP19 Good Practice Recommendations Damaged flooring in toilet area should be replaced to enhance safety. 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. Wheelchair storage room be made secure The management provide the CSCI a refurbishment/development plan for the Old Vicarage site for period 2006/07. Ensure all wardrobes are secured to adjacent walls. Protective over-garments be provided for access to kitchen area. The practice of storing items on toilet pedestal lids cease forthwith, and ensure toilet roll holders are maintained. Supervision of carers is to be formally documented six times a year. That COSHHE signs and information be displayed in all areas involving the use of hazardous chemicals, i.e. destainers. To maintain adequate hours of maintenance and laundry staff. (Previous timescale 01/04/05). To maintain adequate hours of laundry staff. Secure a suitable container for Controlled Drugs 3 4 OP38 OP33 5 6 7 8 9 OP38 OP19 OP38 OP36 OP26 10 11 12 OP27 OP27 OP9 Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 26 13 OP19 Review of kitchen flooring Wilbraham House Residential Home DS0000005035.V287028.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Wilbraham House Residential Home DS0000005035.V287028.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. 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