Inspection on 06/08/07 for Wilford House

This inspection was carried out on 6th August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Wilford House 03/07/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Wilford House 47 Rowley Bank Stafford Staffordshire ST17 9BA Lead Inspector Sue Jordan Key Unannounced Inspection 6th August 2007 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 Wilford House DS0000005036.V341842.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.V341842.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.V341842.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2006 Brief Description of the Service: Wilford house is situated on the outskirts of Stafford Town Centre and is registered with the Commission for Social Care Inspection to offer care to thirty-one older people. At the time of the inspection there were twenty-six people using the service. The home is run as a non-profit making business by Stafford Eventide Homes Ltd. The home is comfortable and well maintained and all of the people using the service have their own bedroom to which they can bring their personal possessions. Bathing and toilet facilities are located throughout the home and near to the bedroom and communal areas. There is a paved garden at the rear of the home. Mrs Maureen Pownall, who has worked at the Home for many years, manages Wilford House. The fees range from £357 to £416:50. The people using the service have to pay for hairdressing, private chiropody, personal newspapers, toiletries and public transport. Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven and three quarter hours. Being a ‘key inspection’ all the core standards were assessed. The methodologies used were: A day of preparation before the inspection, including scrutiny of the Commission for Social Care Inspection Annual Quality Assurance Assessment completed and returned by the manager. A number of surveys were sent out and ten were received from people using the service, five from relatives and two from health professionals involved at the Home. The results were analysed and direct quotes have been included in this report. During the visit, the inspector met and spoke to a number of the people living in the home and discussions were held with the manager, senior support worker, two care staff and the cook. Observations were made of staff and service user interaction and non-personal care tasks. The medication systems were checked and a walk round the home taken. Two residents’ care records were checked. The service users financial records were also checked. One staff recruitment files was examined and also the staff training records. A random selection of the Health and Safety and maintenance records were examined. The last Key Inspection was in July 2006. Ten requirements and twenty-one recommendations have been made as a result of this inspection. What the service does well: Wilford House provides a homely and clean environment for the people using the service. Each person has their own bedroom and there are various communal rooms in which people can choose to sit. Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 6 There is a family-type atmosphere in the Home. The manager and many of the staff have worked at Wilford House for some time and a pleasant atmosphere and banter between them and the people using the service was observed. Before moving into Wilford House, a person is assessed by the Local Authority and/or the management of the Home. This ensures that the Home can meet their needs. Relatives commented that they were provided with good information about the Home, enabling them to make their choice. The response from relatives indicated that generally people are very happy that they chose Wilford House and comments included: “My relative needs a lot of care now and could not be in a better place to receive it”. “All of my relative’s needs are catered for and probably gets more care than we originally agreed”. The health of the people using the service is closely monitored and access to medical intervention is provided as and when necessary. The Home has close links with local general practitioners and district nurses. Visitors are made welcome. The people using the service are given a choice of meals and they can take their own possessions into the Home. The people using the service and their relatives are complimentary about the meals at Wilford House and comments included: “Very satisfied with meals, there is always a choice”. “My relative often comments how excellent the food is”. Wilford House is able to cater for people with diabetes and provide assistance for those who need help to eat. There have been no complaints about the care provided at Wilford House and relatives and people using the service say that they feel able to approach the management team with any concerns. One relative said, “Either the manager or deputy manager are always available for minor matters and there are complaints and disputes procedures outlined in our original agreements”. Records of kept of all financial transactions made on behalf of the people using the service. Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 7 Staffing numbers are maintained at a safe level and there is always a member of the management team on-call. The people using the service and/or their relatives were positive about the staff working at Wilford House and comments included: “Staff treat my relative with respect and kindness at all times; gentle handling, patience and understanding. All the staff are very friendly and helpful to the residents and visitors”. More than 50 of the care staff have achieved National Vocational Qualification 2 in care. Wilford House has robust recruitment procedures in place and staff are not allowed to work in the Home until all the required checks have been made and the manager is satisfied that the people using the service are safeguarded. What has improved since the last inspection? What they could do better: Wilford House needs to improve its recording mechanisms and monitoring practices to ensure that they continue to provide the support that the people using the service need and want. This particularly refers to the development of a Quality Assurance system. The people using the service and/or their relatives should be offered the opportunity to be involved in planning their care and this could be evidenced within the care plans themselves. The Home could consider developing some of its documentation in different formats, for example bold print, pictorial or photographic formats. This will enable people using the service with diverse needs to access relevant information. This could include the Statement of Purpose, Service Users Guide and the complaints procedure. The manager needs to monitor the medication practices in the Home, including administration and stock control. Although all of the staff responsible for the administration of medication have received training, they need to be reassessed at regular intervals to check that they remain competent. Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 8 Records should be stored individually and not placed together in one file, to ensure that they comply with the Data Protection Act 1998 and respect privacy. Many of the relatives said that they thought more activities could be arranged for the people using the service and this was confirmed during the inspection. The Home has organised an annual fete and BBQ, two different church groups come into Wilford House and occasionally an entertainer is arranged. If there is enough staff they will sometimes organise a game, however some of the people using the service say that they are bored and that there is only the TV. Following consultation with the people using the service a more structured programme of activities needs to be provided. The manager was advised to record all concerns made and addressed as evidence that she takes all concerns seriously and takes appropriate action to resolve them. The present bedroom door locks do not comply with fire safety requirements and therefore the people using the service are unable to use them. A number of gaps in staff training were noted including infection control, adult abuse and food hygiene. The manager was able to verbally confirm that she was aware of these gaps and that training is being planned, however she needs to develop a better way of monitoring training, which should include an annual appraisal for all staff. She was advised to develop a training matrix. Staff are not being formally supervised and this needs to be addressed to improve the outcomes for the people using the service. The manager needs the time and support to address some of the issues identified during this inspection. Someone from Stafford Eventide Homes Ltd should be undertaking unannounced, monthly monitoring visits and the manager should be being supervised. She also needs the time to complete her training. Some duties could be delegated to other staff so that they can feel more involved and allow the manager to monitor the overall service. 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.V341842.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The needs of people wishing to move into the Home are carefully assessed and information is available to them in a standard format. The staff care for the people using the service in a kind and sensitive manner, although this must be supported by a more robust and regular training programme to ensure that their knowledge is kept up to date and meets the diverse needs of the people using the service. EVIDENCE: The Statement of Purpose is pinned to the board in the front lobby area. The manager is aware that it needs updating. It is recommended that this document be dated at each review as evidence of its currency. The manager reported that a Service Users Guide is also available. At present Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 11 the views of the people using the service are not included with this document, as a structured Quality Assurance system has not been developed. A number of questionnaires were completed by people using the service and/or their relatives and sent to the Commission for Social Care Inspection before this visit. All of the responses indicated that they had been given the necessary information about the Home before deciding whether to use the service. They also said that they had received a contract. Comments included: “We had a very detailed view of this home. Made us very welcome, which is important when you have to make this decision”. Before deciding whether the Home is able to meet a prospective resident’s needs, the manager obtains an assessment and care plan from the Local Authority. In the case of a privately funded person the manager carries out her own assessment. The completed questionnaires indicated that the majority of the people using the service and/or their relatives feel that the Home is able to meet their needs. Comments included: “My relative needs a lot of care now and could not be in a better place to receive it”. “All of my relative’s needs are catered for and probably gets more care than we originally agreed”. A number of gaps in the staff training requirements were identified during this inspection including Adult Abuse, Infection Control and Food and Hygiene although some courses have been arranged to address this. The people using the service and/or their relatives comment positively about the staff and the management team and their kindness. This needs to be reinforced and supported by a robust and regular training programme, which includes the mandatory Health and Safety subjects and supplementary courses specific to the needs of the people living at Wilford House. Wilford House is not registered to care for people with dementia care needs, although they are able to continue supporting people who become more confused with age. Some staff have attended a ‘dementia awareness’ course, although the manager said that she would like to plan a more detailed course. It is recommended that some of the Home’s documentation be available in different formats, for example large print, pictorial or photographic, in order that pertinent information is available for those people using the service with more diverse needs. Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 12 The Home does not provide intermediate care. Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 13 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, 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health needs are monitored and appropriate action and intervention taken although the people using the service need to be more involved in planning their care. Medication systems do not always follow good practice or safe practice guidelines and some action is required to ensure that the people using the service are thoroughly safe guarded. The people using the service are treated with kindness and respect. EVIDENCE: The manager has recently developed a new care planning system. These outline the action required by staff to meet the individual person’s needs. Each area of need is detailed on a separate sheet but in some cases blank Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 14 sheets have been left in the files, because there are presently no identified issues. It was suggested that this fact be written on the sheet so that staff do not become confused and think that the information has just not been filled in. At present the manager and deputy are reviewing and amending the care plans and discussions with staff indicate that although they are aware of the care plans, they are not involved and do not access them very often. Staff are however kept informed of any changes during the handover of shifts. Staff complete the personal care records daily, which are currently filed collectively. These should be stored individually in accordance with the Data Protection Act 1998. By placing these records in the individual care plan files, the staff would also become more familiar with the care plans. At present there is little evidence that the people using the service are involved in planning their care. The introduction of a key worker system was also discussed, which might encourage more staff and resident involvement. This would also assist the manager, who is trying to do everything herself. There is ample evidence that the staff and management monitor the health of the people using the service and access medical professional support when required. On the day of this inspection different general practitioners visited five residents. The district nurse also visited one person. Comments cards were received from one general practitioner and a district nurse, which were both positive about the service provided at Wilford House. The people using the service and/or their relatives were asked in the questionnaires whether the home met their health needs and the responses were 99 positive. Comments included: “They are very thorough with medical needs”. “They sometimes pick up problems with health before they are obvious to my relative”. This inspection included examination of the medication procedures in the Home. The manager, deputy manager and senior care workers have completed the ‘Safe Handling of Medicines’ training and they also receive training from the pharmacist. The pharmacist also visited the Home in September 2006 to check the medication systems. Some issues were identified during observation of the lunchtime medication administration: the staff must make sure that they do not handle the tablets and the medication must be dispensed immediately and not stored in a pot to be given later, (secondary dispensing). The staff take the medication trolley Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 15 upstairs to be securely locked away following administration and therefore are able to dispense directly. The manager needs to introduce a competency check for staff so that she can monitor that staff are still following the correct procedures. The administration sheets are completed correctly and there were no gaps in the records. The medication is securely locked away. The stock was checked and two items were found to have expired. These must be returned to the pharmacist. It is also recommended that creams and eye drops be dated on opening to ensure that they are used within the required timescale of expiry. There is a separate book for the recording of controlled medication, however this should also include a running balance so that the staff can check that the medication has been given correctly. A number of the people using the service are prescribed PRN or ‘As required’ medication. The manager explained the procedures for the administration of this medication, however it is recommended that she ask the relevant general practitioners to sign a protocol to ensure that it is given in the right circumstances and according to the prescriber’s instructions. Observation during this inspection and comments received by the people using the service and/or their relatives indicated that privacy and dignity is respected. Comments included: “The residents can have company if they want it or privacy if they don’t”. “It is good to have my relative in a home that clearly is aware of the needs of the elderly and treats them with respect in a family environment”. Each of the people using the service has their own bedroom where they can spend time alone or receive visitors. There are also quieter areas in the home where people can go. One relative expressed a concern that his or her relative could not go to their room during the day. However discussions with various people using the service suggested that this was not the case and people were observed to go to, or be in their rooms. There is a phone booth available for private calls. The people using the service were taken to the privacy of their rooms when receiving a general practitioner visit. Two residents have sadly recently died and discussions with the staff and the manager indicated that they handle these sad situations with genuine feeling and concern. Friends and relatives of the people who recently died visited the Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 16 Home during the inspection and were treated with care and respect. They also spoke positively about the Home, the staff and the manager. A district nurse has given the manager information about a palliative care course for the staff. Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. Visitors to the Home are made welcome and there is a choice of home cooked meals available. Events are periodically arranged for the people using the service, however there are few activities or outings provided throughout their daily lives. EVIDENCE: Some people using the service and/or their relatives made comments that there are insufficient activities provided. These included: “More social activities are needed i.e. outings, games etc to stimulate/support mental activity”. “My relative is extremely deaf and finds it difficult to participate”. “It is a pity that outings cannot be arranged on occasion. This may be difficult Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 18 because many of the residents have mobility problems, but a simple trip out could provide a little excitement”. One resident said, “There is very little to do, either TV or music”. Discussions with some of the people using the service indicated that they got bored on a daily basis and that TV is the main activity. A fete recently took place and a BBQ is arranged for the end of August. A ‘cheese and wine’ evening has been arranged for October. The manager and some staff said that they do have access to some games and occasionally if they have time, these are played. These include bingo and magnetic darts. Staff completing their National Vocational Qualification training sometimes have done exercises with the people using the service. They did report that it could be difficult to motivate some of the people using the service to get involved. There are two different Christian denomination groups that come to the Home regularly to offer communion and hymn singing to the people using the service. The people using the service are able to choose whether they attend or not. It is recommended that a more structured daily activities programme be introduced. Where possible the people using the service should be consulted as to what they would like to do and this could be discussed in a residents’ meeting or when discussing their care plans. There are various communal areas in the Home and one could be set aside so that the people using the service can choose whether or not to attend. Given time and with staff enthusiasm the residents may be encouraged to get involved. Singers and entertainers do occasionally come into the Home. It is recommended that records of activities requested and subsequently enjoyed by the people using the service be kept in the individual care records. The comments received from families indicate that they are made welcome when they visit and this was confirmed during the inspection. Relatives and friends were visiting constantly throughout the day. Discussions with some of the people using the service confirmed that they could go to bed and get up when they wish and some choose to have their meals in their bedrooms. People have been encouraged to personalise their own bedrooms. The people using the service are very positive about the meals provided at the Home and comments include: “Individual needs are met, alternative food is provided and the meals are well presented & tasty”. “Very satisfied with meals, there is always a choice”. Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 19 “The food is good and individual needs are catered for”. “My relative often comments how excellent the food is, how much choice there is and that they are aware of his or her preferences”. All of the residents spoken to during the inspection praised the food. The cook on duty and the manager reported that good quality ingredients are available and that the meals are mainly ‘home made’. There is an ample supply of fresh fruit and vegetables. The Home caters for three people with diabetes and some people require assistance to eat. This is usually done in the privacy of their own bedrooms. A choice is available to the people using the service. They are offered two choices of main meal at lunchtime and alternatives are available. The cook will also ask the residents what they would like to have for tea. At present there is no actual menu, although records are kept of the food provided. It is recommended that a four week menu be developed, which will aid with meal planning and ensure that a balanced, varied menu is provided. The menu should include choices and alternatives should continue to be available. The cook on duty has worked at the Home for three months and is well qualified. The catering staff work full time and therefore the care staff do not often have to be involved in meal preparation. However they regularly come in and out of the kitchen making drinks for the residents and may occasionally be asked to prepare a simple snack, therefore they should have training in the basic principles of food hygiene. The Environmental Health Department visits the Home annually and the Home complies with their requirements and recommendations. Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 20 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. This judgement has been made using available evidence including a visit to this service. There is an open culture in the Home and people using the service are able to approach the management with their concerns. This could be further encouraged and enabled with a better Quality Assurance system. The people using the service are protected by the Home’s recruitment procedures. EVIDENCE: There have been no complaints made either to the Home or to the Commission for Social Care Inspection. The questionnaires completed by people using the service and/or their relatives indicate that most people know who to speak to if they have any concerns. One relative said, “Either the manager or deputy manager are always available for minor matters and there are complaints and disputes procedures outlined in our original agreements”. The manager tries to deal with issues as they occur and before they escalate. It was suggested that she also record the action taken to deal with these minor concerns, as evidence that she takes them all seriously and takes appropriate action. In order that people using the service and/or their relatives are further Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 21 encouraged and enabled to express their concerns, the complaints procedures could be developed in alternative formats and developing the Quality Assurance systems will also mean that peoples’ views are regularly sought and action taken to continuously improve the service provided. This will help to strengthen the already ‘open culture’ in the Home. Records are kept of all monies being held for the people using the service and all transactions are accounted for. Safe storage is provided. The staff recruitment procedures protect the people using the service. Protection of Vulnerable Adults First checks are made and the results received before a new employee is allowed to work in the Home and Criminal Records Bureau checks and references obtained. The manager is presently arranging additional training for staff in Adult Abuse and the procedures to follow. Staff that have completed their National Vocational Qualifications have covered the basics. During discussions they indicated that they would immediately report any concerns. The manager needs to obtain the new, Local Authority Safe Guarding Adults Policy and Procedure to ensure that she knows the current procedures to follow in the event of a suspicion of or an alleged abusive situation. Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 22 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, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Wilford House provides a clean and well-maintained environment for the people using the service. EVIDENCE: Wilford House is well maintained and presented. There are a variety of communal areas for the residents to choose from and each person has their own bedroom. The present bedroom door locks do not comply with fire safety regulations, although the manager reports that none of the present residents want to lock their rooms. Safe door locks should be fitted to enable the people using the service to additional privacy should they wish it. Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 23 There is a programme of continuing redecoration and the manager reported that new carpets are to be purchased for the conservatory and hall and that the electrical wiring is to be updated. New blinds and solar roof have been provided in the conservatory. All of the radiators have now been covered. The Fire Safety Officer and the Environmental Health Department have visited the Home in the last twelve months. The Fire Safety Officer provided the manager with some information about fire risk assessments. There are three domestic staff and one laundry assistant employed and industrial washing machines with sluice facilities are available in the laundry. There are no unpleasant smells and the home is kept very clean. The care staff need infection control training. Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 24 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. This judgement has been made using available evidence including a visit to this service. People using services are generally satisfied with the care they receive to meet their needs, but there are times when they may need to wait a short time for staff support and attention. The manager is aware that there are some gaps in the training programme and plans to deal with this. The Home’s recruitment procedures meet the regulations and the National Minimum Standards. EVIDENCE: Some relatives expressed concerns about fluctuating staff levels and comments included: “Sometimes at busy times, requests have to be repeated”. “Staffing levels fluctuate”. However, scrutiny of the rotas, observations during the inspection and discussions with the manager and the people using the service indicated that the levels are reasonably maintained. There are presently 26 people using the Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 25 service and in the mornings there are 5 care workers, including 1 senior and the manager. The care staff are also supported by 3 domestic staff, a cook and kitchen assistant. In the afternoons, there are 4 care staff. The manager or deputy work throughout the day and one is always on call. There are 3 night care workers, one of which is a senior. It was recommended that a staff member be delegated to provide activities during the day. Positive comments were received about the staff team and the care they deliver including: “The Care Home does well looking after the residents’ needs on a day to day basis and the care and all the understanding and quality that all of the staff give is just first class”. More than 50 of the care staff have National Vocational Qualification 2 in care. The recruitment procedures are robust. The Home vets potential staff by obtaining Protection of Vulnerable Adults First checks, Criminal Records Bureau disclosures and references. The staff files contain all of the required elements. The manager has started to reorganise the staff files and the example seen was well maintained. A number of training deficiencies were noted. Staff require training in infection control, food hygiene and adult abuse. The manager is currently training to be a manual-handling trainer, which will ensure that the training is specific to the needs of the people using the service. Some training is presently being arranged to meet the deficiencies and the manager is also planning to organise some supplementary courses including pressure sore and wound care, incontinence and catheter care and fire safety. The district nurse has given the manager information about palliative care training. Some staff have attended a dementia awareness course. It was suggested that the manager develop a training matrix, so that she can easily monitor the training and plan the updates. Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 26 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, 36, 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is well liked and respected by the people using the service, their relatives and the staff. She is also aware of the need to develop her management and monitoring skills, but does not have sufficient time or support to do this in a truly effective manner. As a result, management of the Home is reactive rather than evaluated and planned. EVIDENCE: The manager, Maureen Pownall has worked at Wilford House for many years and became the manager approximately seven years ago. She had started to undertake the Registered Managers Award and National Vocational Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 27 Qualification 4, however she ran out of time and she has to reapply. She needs to register and get these qualifications as soon as possible. A deputy and two senior care workers support the manager. Discussions with the staff and people using the service indicate that the manager and deputy are approachable and operate an open door policy. Although at present the people using the service and/or their relatives are generally happy with the care delivered at Wilford House there is no formalised Quality Assurance system in place. The management do not send out surveys or hold residents’ meetings and staff supervision is insufficient. Robust Quality Assurance should allow all parties involved to express their views about the care home and the results used to self monitor the service provided. The results of any quality audit should be compiled and a report be available to the people using the service and the Commission for Social Care Inspection. It is recommended that the Home use the National Minimum Standards, Care Homes Regulations as the basis for their Quality Assurance systems. The Annual Quality Assurance Assessment, (AQAA) and Key Lines of Regulatory Assessment, (KLORA) developed by the Commission for Social Care Inspection could also assist in this process. The Home is owned by Stafford Eventide Ltd, which is a non-profit making organisation. The manager reports to a committee made up of volunteers. There is evidence that members of the committee do visit the Home, however they do not complete monthly, unannounced visits as dictated by Regulation 26 of the Care Homes Regulations 2001. The registered person should undertake monthly, unannounced visits during which he should interview, with their consent and in private, staff, representatives and the people using the service, in order that he can form an opinion of the standard of care in the Home. He should also inspect the premises, its records of events and records of any complaints. A written report must be prepared regarding the conduct of the care home. A copy of this report must be sent to the manager and available to the Commission for Social Care Inspection. These visits can also form part of the Home’s Quality Assurance procedures. Records are kept of all monies being held for the people using the service and all transactions are accounted for. Safe storage is provided. The money of one person was checked against the recorded balance and found to be correct. The staff say that they can approach the manager at any times, however there is no evidence of formalised supervision. The manager needs to implement a regular system of supervision, which includes individual sessions and appraisals and team meetings. There is a handover at the beginning of every shift, where information about the changing needs of the people using the service is relayed. Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 28 It is recommended that the people undertaking supervision of staff be trained to do so. The manager also needs to be supervised and supported. It is recommended that the manager delegate some duties to other staff, including care planning, organising activities and the supervision of some staff. This will allow the manager to oversee and monitor the service more effectively. The manager was reminded that residents’ records should be stored individually in accordance with the Data Protection Act 1998. A random selection of maintenance and Health and Safety records were checked and generally they provide evidence that the Home complies with Health and Safety legislation. It is recommended that the manager review the environmental risk assessments at least annually. Individual fire evacuation procedures need to be developed, which are based on a robust fire risk assessment. These should be completed by a competent person. The manager is aware that the staff need up to date fire safety training and is planning the next round of fire drills for all staff. Mandatory training must be provided to staff at the required frequencies to ensure that the staff carry out safe working practices, protecting both them and the people using the service. Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 29 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 3 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 2 3 2 Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (2a, c, d) Requirement The manager must make the care plans available to the people using the service and consult and notify them of any review or amendment, so that they are involved in planning their care. The manager must ensure that the administration of medication is carried out in a hygienic manner to lessen the risk of infection to the people using services. Out of date drugs must be returned to the pharmacist to ensure that the people using services receive the correct medication. The controlled drugs register should show the balance of drugs in stock to enable the manager to monitor and ensure safe practice. Following consultation with the people using the service a programme of activities must be arranged, which meets individual needs and wishes. The staff must receive training DS0000005036.V341842.R01.S.doc Timescale for action 01/10/07 2 OP9 13 (2) 01/10/07 3 OP9 13 (2) 01/10/07 4 OP9 13 (2) 01/10/07 5 OP12 16 (2m,n) 01/11/07 6 OP30 18 (1ci) 01/11/07 Page 31 Wilford House Version 5.2 7 OP33 24 8 OP33 26 9 OP36 18 (2a) 12 (1a) 10 OP37 23 (4, d, e, ciii) appropriate to the work they are to perform. This includes mandatory training and training specific to the needs of the people using the service. This will ensure that the people using the service are supported by staff qualified to meet their needs and maintain their safety. A Quality Assurance system must be established and maintained, which includes the views of the people using the service and/or their representatives. A report must be compiled, which sets out the action to be taken and this must be available to the CSCI, the people using the service and their representatives. This will ensure that a good quality service is being provided and that people are satisfied with it. The registered provider must carry out monthly, unannounced visits to monitor the service provided and inspect the premises. A written report must be prepared regarding the conduct of the care home, which is available to the manager and the CSCI. The staff must be appropriately supervised to ensure that the care provided maintains the safety of the people using the service and meets their needs. Adequate arrangements must be made for fire safety, including fire evacuations procedures, which take the individual needs of the people using the service into account. 01/11/07 01/10/07 01/10/07 01/10/07 Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 32 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 It is recommended that the Homes documentation be developed into differing formats so that those people using the service with more diverse needs can also have access to relevant information. 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 Home needs to examine ways in which they can demonstrate that they are able to meet the diverse needs of the people using the service. This includes staff training and supervision. It is recommended that staff become more involved in care planning to ensure that they know the needs of the people using the service and the action required to meet them. This could be achieved within a key worker system. It is recommended that the date of opening be added to creams and liquids to ensure that these are given within the correct expiry timescales. Protocols should be developed for the use of PRN/ ‘as required’ medication to ensure that the staff know the exact circumstances in which to administer this medication safely. If possible the prescriber should sign these. It is recommended that the activities enjoyed or refused by the people using the service are recorded, so that the home can monitor the success of the activities provided and ensure that they are able to enjoy varied and stimulating lives. The Home should examine ways in which they can help the people using the service to access the community. A menu should be devised to ensure the planning of a varied, interesting and nutritious diet for the people using the service. All concerns and complaints should be recorded to evidence that the Home takes all concerns seriously and takes appropriate action to resolve them. DS0000005036.V341842.R01.S.doc Version 5.2 Page 33 2 OP1 3 OP4 4 OP7 5 6 OP9 OP9 7 OP12 8 9 10 OP13 OP15 OP16 Wilford House 11 OP18 12 13 14 OP24 OP31 OP32 15 OP33 16 17 18 19 20 21 OP36 OP36 OP37 OP38 OP38 OP28 The manager should obtain the Local Authority Safe Guarding Adult procedures to ensure that all staff know how to respond in the event of an abusive situation or allegation. Bedroom door locks should be fitted, which comply with fire safety legislation but afford the people using the service with privacy if they require it. The manager needs to complete the Registered Managers Award and National Vocational Qualification 4. The manager should be given the time and opportunity to undertake her management responsibilities. This includes completing the Registered Managers Award and National Vocational Qualification 4. The Home is advised to use the Commission for Social Care Inspection’s KLORA and AQAA documents as a basis for their Quality Assurance. This will assist them to involve the people using the service in decision-making and to comply with legal requirements. Those people responsible for supervising staff should receive training to ensure that it is effective and benefits the people using the service. Staff should be supervised in a variety of ways, including one to one sessions with a manager, annual appraisals and attendance at team meetings. Records should be filed individually to comply with the Data Protection Act 1998 and ensure a person centred approach for the people using the service. The Health and Safety of the building should be monitored and audited at regular intervals. 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. The monitoring of fire safety and Health and Safety issues should be carried out by appropriately qualified people. Wilford House DS0000005036.V341842.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Birmingham Local Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ 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.V341842.R01.S.doc Version 5.2 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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