Inspection on 03/07/08 for Wilford House

This inspection was carried out on 3rd July 2008.

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.

Other inspections for this house

Wilford House 06/08/07

Wilford House 26/07/06

Wilford House 17/08/05

Wilford House 25/04/05

Wilford House 10/08/04

Wilford House 27/04/04

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Wilford House 47 Rowley Bank Stafford Staffordshire ST17 9BA Lead Inspector Mandy Beck Unannounced Inspection 09:00 3rd, 4th July 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 Wilford House DS0000005036.V367363.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. Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wilford House Address 47 Rowley Bank Stafford Staffordshire ST17 9BA 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) 01785 258495 F/P 01785 258493 Stafford Eventide Home Limited Mrs Maureen Elizabeth Pownall Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th August 2007 Brief Description of the Service: Wilford house is situated on the outskirts of Stafford Town Centre. It is accessible by public transport. The home only has places for 30 people after they decommissioned one double room and has now made this single occupancy only. Wilford house offers a home to 30 people. Each person has their own bedroom and people are encouraged to bring in their personal possessions to make their rooms their own. The home is comfortable and well maintained. Bathing and toilet facilities are located throughout the home for people’s comfort. There is a paved garden at the rear of the home and car parking space at the front. The Service User Guide does not include the range of fees people are expected to pay for residency. People reading this report are asked to contact the home directly for this information. The latest inspection report is displayed in the reception area for people to read. Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use this service experience adequate quality outcomes. We looked at all the information that we have received, or asked for, since the last key inspection. This included: • The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. • Information we have about how the service has managed any complaints. • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. • Relevant information from other organisations. • We also spent time talking to the people who use the service and to the staff who support them. • We looked at the care of three people who use this service in depth. This is part of our case tracking process and helps us makes judgements about the home’s abilities to meet people’s needs. What the service does well: What has improved since the last inspection? Since the last inspection the home has replaced people’s beds, redecorated some areas of the home with more planned. The home has been completely rewired for people’s added safety. Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 Page 6 The company has employed the services of a consultancy company who are working with the home in developing the quality assurance system and the home’s record keeping systems. The manager and staff hae worked very hard to improve the activity provision in the home. Activities are now taking place at least twice a day and appear to be enjoyed by all the people living in the home. People said “I like the card games but there’s so much to do now they have tried really hard”. 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. The summary of this inspection report can be made available in other formats on request. Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 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 Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Quality in this outcome area is good. People who may choose to use this service do not have up to date information upon which to base their decisions. Each person can be assured that a detailed assessment of his or her needs will be completed prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service User Guide are on display in the hallway of this home. They do not however give people up to date information about the service and what they can expect from the home once they agree to move in. We have recommended both documents are reviewed and for the home to included details of the range of fees it charges people for residency. This will make sure that people are given up to date current information about the home. The review of these documents was recommended in the homes last inspection report and must now be actioned. Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 Page 9 We looked at the care records of two people currently living at the home. We did this as part of our case tracking process that enables us to make judgements about whether the home is meeting the needs of the people who live there. We saw that in both cases a comprehensive assessment of need had been obtained from the placing social worker. The home had also complimented this by visiting the person at home prior to admission. The manager will do this so that she can be sure people’s needs can be met. A new assessment of daily living needs is currently in the process of being implemented, this will add the to the admission process and ensure that each person’s needs are thoroughly assessed prior to admission. Once both parties have agreed admission the home will write to people and confirm that they can meet their assessed needs. People are invited to visit the home before making a choice and stay for a meal and talk to other residents if they choose to do so. The home does not offer intermediate care facilities. Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. People who use this service do have their healthcare needs met. Medication systems in the home are generally satisfactory and protect the health and welfare of the people living there. People living in this home can feel confident they will be treated with respect and dignity at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person has their own care plan that details most of their needs. Plans we saw did not really contain enough information about people’s choices to guide staff when performing care. Care plans were pre printed and do not lend themselves to a person centred approach to care planning. The manager did tell us the home had worked hard to develop the care planning systems but she was aware that more could be done to improve them. The consultancy company the home has employed to improve the record keeping is currently redeveloping the whole care planning system. Once this is done it is hoped that people’s individual choices and preferences will be included in a person centred plan of care. Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 Page 11 Despite the limited information available about people’s care needs staff were able to give clear verbal updates on people’s conditions and demonstrated they understood what each person wanted when it came to providing their personal care. The home completes some risk assessments but in order to further protect people more are needed. We have recommended the introduction of a falls risk assessment, a pressure sore risk development assessment and a nutritional screening tool. The addition of these risk assessments along with the current moving and handling assessment will ensure the home is taking active steps to identify those people at risk and enable them to plan preventative measures to reduce risks to the people using this service. There was evidence to show people do receive the care and treatment they need from other healthcare services to. This included regular visits from their own doctor, the district nursing service and specialisms such as the speech and language therapist. People living in this home said “sometimes you have to wait for the toilet at busy times”, “if I feel unwell Maureen (manager) always calls the doctor for me”, “I couldn’t ask for any more I am happy here”. Medication management has been improved in the last year. The outstanding requirements from the last inspection have now been met. All out of date medicines are returned back to the pharmacy and the controlled drugs register has been updated. The home’s policy for administration of “as required” medicines has been reviewed and is about to be put into practice. This will mean there are clear records for staff to follow when considering the administration of “as required” medication. The new policy also tells staff they must see the prescription before it goes from the General Practitioner (GP) to the pharmacy for dispensing. This currently does not happen and staff must address this. This should be done to reduce the risk of error and will make sure that people are getting their medication as it is prescribed. Further improvements to medication practices include the recording of temperatures in the medication storage room and the drugs fridge on a daily basis. This will ensure the medication is being stored at manufacturers recommended temperatures. Each Medication Administration Record (MAR) that has a handwritten entry should have two staff signatures on it, this will reduce the margin for error when copying information on the to MAR and reduce the risk of error to service users during administration of medicines. Throughout this inspection is was clear that people are treated with respect and dignity. We saw staff assisting people to the toilet, dining tables and Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 Page 12 comforting them when they felt unwell. Staff were seen to knock on people’s doors before going in. One person told us “my dear they are lovely girls here, they do really look after us and make it feel like home”. One person commented “Staff do not always comply with what I want to wear each day. I cannot get my things out of the wardrobe now and rely on help with dressing. I feel my wishes on what I want to wear should be respected”. When we spoke to staff they told us about each person own individual likes and dislikes and their preferences for care. They said “ we really try hard to help the residents here, I think we look after them so well and can’t praise it enough”. Wilford House DS0000005036.V367363.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): 12,13,14,15 Quality in this outcome area is good. People using this service do have an extensive choice of activities to do in the home. They are supported by the home to maintain friendships and family contacts. People old us the food is very good and there is a good choice of food that meets a variety of peoples needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since our last visit the home has worker hard to improve the activities available for people to take part in. There is now a wide range of activities on offer both morning and afternoon. These range from board games, quizzes and bingo to exercises, pass the parcel and sing alongs. We had the opportunity to observe a game of “card bingo” during this inspection. It was clear that people were enjoying this. Everyone was taking part and staff assisted those people who needed it in a sensitive manner. One person said “I don’t understand it but its really good fun and I won a prize yesterday”. We spoke to staff who said “we have really embraced the activities, we are all working hard to think of more. I can’t believe what a change its made, its brilliant”. We asked if there are any improvements they would like to see, they Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 Page 14 told us “a minibus would be great so we could take more people out”, “it would be nice to get more people outside because they really enjoy it”. Throughout this inspection there was a steady stream of visitors. People are supported to meet their visitors in the communal areas or in the privacy of their own rooms. When we looked around the home we saw that people are encouraged to decorate their rooms with personal possessions and furniture from home. People have lockable facilities in their own rooms so that they can keep valuables safely. The home also has its own arrangements for safe keeping of people’s money. Mealtimes are relaxing, the dining room is pleasantly decorated and people told us the food was very nice. “There is always a good choice and if we don’t like it the cook will sort something out”. “The food at Wilford House is excellent. A lot of trouble is taken catering for individual needs”. We had the opportunity to taste some of the food during this inspection; it was very tasty and presented very nicely. There is no set menu in place, the manager explained the home had tried this previously but residents had found it too restrictive and repetitive. Meals are now prepared daily and three choices are offered to people. The home buys a lot of fresh produce from local suppliers. People who have special dietary requirements can be accommodated here. Wilford House DS0000005036.V367363.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 adequate. People can feel confident their views will be listened to and acted upon however policy updates would give them added guidance when making a complaint. The staff in this home need further training in safeguarding vulnerable adults to ensure they do not take matters into their own hands should an allegation of abuse be made to them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does have a complaints policy but it needs to be reviewed and updated. It does not give people clear information about who to refer complaints to, who will be investigating their complaint or a timescale for completing the investigation. People need to have clear information about other services they can speak to if they are not happy with any aspect of the service provision as well. It is acknowledged the home has included details of how to contact the Ombudsman but they should also list the local Social Services Customer relations department and the Commission’s Customer Services line. People who answered our surveys told us they were all aware of how to make a complaint should they wish to do so. The home has recorded no complaints since our last visit and we, the commission have received no concerns about this service. Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 Page 16 The homes policy for safeguarding vulnerable adults and management of violence and aggression are outdated and do not reflect recent changes in legislation. This means that staff may be guided by out of date information and could potential place people at further risk as a result. We spoke to staff about their knowledge and training of Safeguarding vulnerable adults. They told us “I haven’t had any training in it yet but I am sure I will get some”, “I did some prior to coming to work here but none at the home”. Staff did show some understanding of what abuse is and the different types but were not clear about the process to take should an allegation of abuse be made to them. They said, “I would investigate, report it and talk to staff”. Investigation into any allegation of abuse must be done in partnership with the local council. The home currently does not have a copy of this guidance. We have recommended this is obtained and staff familiarise themselves with the contents. The home does take appropriate action when recruiting staff by completing safety checks such as a check against the Protection of Vulnerable Adults list (PoVA) and Criminal Records Bureau disclosures (CRB). Both of these checks will help prevent unsuitable people from working with vulnerable adults. The home must make sure that when staff begin working in the home with only a PoVA first check in place, they are kept under supervision and the whole process is risk assessed until the satisfactory CRB is returned. The home must make sure that each person who uses bed rails has their own individual risk assessment for their use. This does not happen at present. We saw one person’s bed had rails attached to it, the manager confirmed that risk assessments are not in place. Bed rails can pose a significant risk to the health and welfare of people who use them; they must be properly maintained and assessed before they are used. Once risk assessments are in place they must be kept under regular review. Wilford House DS0000005036.V367363.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): 19,26 Quality in this outcome area is good. People live in a well maintained and clean home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at most parts of the home during this inspection. The home is clean and free from any offensive odours. Communal areas are spacious and are decorated with people’s belongings. There has been some redecoration and refurbishment since the last inspection. The home has been completely re wired throughout for people’s safety. This means that there are now some small areas of exposed plaster work. The manager told us the home is going to be redecorated throughout very shortly. This will be a positive step in brightening the home up. The manager has also recently purchased over 20 new beds for people’s added comfort. Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 Page 18 A new boiler is to be installed in the coming weeks following a problem with the heating. The home was warm enough during this inspection but people have said “its been sweltering hot and then cold, not for long though I think its sorted out now”. Staff told us they were going to be having training in infection control. Another said, “we have had some training, we were taught good hand washing techniques”. The home also takes steps to reduce the risk of infection spreading by making sure there is liquid soap and paper towels available in toilets and bathing areas for people to use. There are laundry facilities on site and the home has dedicated staff that complete this job. Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. People are supported by a staff team that is consistent and who understand their needs. The home must improve the training provision for staff to make sure they are kept up to date with changes in legislation and practice so that people are not placed at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has sufficient numbers of staff on duty to meet the current needs of the people who live here. The care team are supported by catering, domestic and laundry staff. People using the service said “staff are great”, “don’t know what I’d do without them”. Some of the staff have completed their National Vocational Qualification (NVQ) level 2 and others are currently being supported by the home to complete it. This means staff will have some of the knowledge and skills they require to complete their duties. Other training is needed to supplement the NVQ, at present this is out of date and needs to be addressed. The manager told us training has been arranged and during the inspection a list of training dates were faxed through indicating the training had been booked. The manager confirmed that the current dates would not cover all the staff and additional dates would need to be added to this provisional listing. Staff training is an outstanding requirement from the last inspection and must be addressed. The Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 Page 20 commission will be considering further enforcement action it this is not addressed. We looked at the recruitment processes in the home and the staff files of three new workers. It was pleasing to see that most of the required information was contained in people’ files. We have recommended a few improvements for the home to make. References should not be accepted “to whom it may concern”, if the manager receives a reference with this, she must be able to demonstrate how she has taken steps to authenticate the reference in the staff members file. Application forms in use varied and asked for different information. It is recommended the application form be standardised and also include a full employment history for the worker. When new workers are employed the home does complete a brief induction with staff. We have recommended the induction process is reviewed and the induction programme be developed in line with the Skills for Care Common Induction Standards. This will ensure that staff are receiving the training and support they need when beginning employment in a social care setting. Staff we spoke to said “the home has been great, I do get a lot of support I am doing my NVQ training now”. Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. The home is managed well and is run in the best interests of the people living there. Improvements to the quality assurance system and staff training are needed though. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is managed by Mrs Maureen Pownell, she has many years experience of managing and of working at Wilford House. Mrs Pownell is respected by both staff and the people who live there. They have told us “Maureen is lovely any problems she’ll sort them out”, “the manager is very approachable and nothing is too much trouble”. Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 Page 22 Mrs Pownell has told us of the improvements to the service she is eager to make. She knows that work is needed on the care planning systems within the home, the policy development and the quality assurance system. In order to help her do all of this work the registered owners have enlisted the help of an consultancy company. The company is working with the home developing new care plans, risk assessments and developing a training programme for staff. In addition to this they will be providing the home with a workable quality assurance system and making sure the staff have training in how to use it. These improvements are necessary if the home is to move forward and improve the outcomes for the people living there. A robust quality assurance system will enable the home to engage with the people living there and make sure they are running the home in their best interests. In addition to this the home’s policies and procedures should be reviewed and updated. At present the contents of some of the policies is insufficient and does not offer clear and concise guidance for staff or the people living in the home. For example the home’s complaints policy as previously mentioned. The registered provider or a representative must make an unannounced visit to the home once a month. They must do this as part of their responsibilities under regulation 26 of Care Home Regulations 2001. We have recommended the home obtain the CSCI guidance on Regulation 26 visits. It is acknowledged that people from the management team for the home do visit on a weekly basis already. We looked at systems for safekeeping of people’s money and found they were in good order. The home has good records of all transactions and obtains receipts and two signatures. This will reduce the risk of errors occurring with people’s money and give the added peace of mind to the people living in the home. Health and safety practices are satisfactory however staff do need mandatory training. This is an outstanding requirement that requires urgent action now. The manager has told us the consultancy company are arranging training for staff to attend. A fax was sent through during the inspection with some dates on for training however both CSCI and the manager agreed that these dates were not enough to make sure all of the staff receive the training they need. More dates must be arranged to accommodate this. Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 2 Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 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 OP18 Regulation 13 (4) Requirement People who are using bed rails must have an individual risk assessment in place for their use. The risk assessment must be kept under regular review. Timescale for action 01/09/08 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 OP1 Good Practice Recommendations The Statement of Purpose and Service Users Guide should be reviewed annually and it is recommended that a review date be added as evidence of this. This will ensure that the people using the service have access to current information. The Service User Guide should include the range of fees it charges people to live in the home. This will give people the information they needs about whats included and whats not in their fees. Care plans need to be developed so that they reflect a DS0000005036.V367363.R01.S.doc Version 5.2 Page 25 2. OP1 3. OP7 Wilford House more individual approach to care planning. Pre printed care plans can be inflexible and do not demonstrate individuals choices and wishes. 4 OP9 It is recommended that staff record the temperature of the treatment room on a daily basis. This will ensure that medication is stored at below 25oC and manufacturers instructions. Staff should also provide a written record that the temperature of the drugs fridge gas also been recorded for the same reasons. Hand written MAR should have two signatures, must have a name of the drug, the route of administration, the dose and the frequency of administration on the MAR sheet. The manager should obtain the local council’s Safeguarding Adult procedures to ensure that all staff know how to respond in the event of an abusive situation or allegation. The home should arrange further training dates for staff training to make sure that all staff have the opportunity to take part. The home needs to continue to develop and implement the Quality Assurance system. The Health and Safety of the building should be monitored and audited at regular intervals as part of the home’s quality assurance system. The environmental risk assessments should be reviewed at least annually to ensure current awareness of any risks, protecting the people using the service, staff and visitors. 5 OP9 6 OP18 7 8 9 OP27 OP33 OP38 10 OP38 Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. Extracts may not be used or reproduced without the express permission of CSCI Wilford House DS0000005036.V367363.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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