Inspection on 10/05/07 for Wilmington Manor Nursing Home

This inspection was carried out on 10th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Wilmington Manor Nursing Home 02/05/08

Wilmington Manor Nursing Home 06/09/06

Wilmington Manor Nursing Home 15/11/05

Wilmington Manor Nursing Home 10/05/05

Wilmington Manor Nursing Home 26/10/04

Wilmington Manor Nursing Home 13/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Wilmington Manor Nursing Home Common Lane Wilmington Dartford Kent DA2 7BA Lead Inspector Elizabeth Baker Key Unannounced Inspection 10th May 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 Wilmington Manor Nursing Home DS0000026214.V338297.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. Wilmington Manor Nursing Home DS0000026214.V338297.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wilmington Manor Nursing Home Address Common Lane Wilmington Dartford Kent DA2 7BA 01322 288746 01322 284403 bazeleym@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Limited 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) Vacant Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50), Physical disability (5) of places Wilmington Manor Nursing Home DS0000026214.V338297.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2006 Brief Description of the Service: Wilmington Manor is a care home providing general nursing care for 50 Older People. Within that total the home may admit up to five Older People with a physical disability. The home is a large detached converted property. Accommodation is provided on the ground, first and second floors. Bedrooms comprise 50 single rooms with ensuite WC facilities. There are two sitting rooms and two dining rooms. All bedrooms have a TV and telephone point. All rooms used by residents are connected to the nurse call alarm. There are two seven-person passenger lifts, one of which accesses all floors. There are wellmaintained gardens, which are accessible for people with a physical disability. Wilmington Manor is located in a rural area and public transport is limited. The home is approximately one mile from the A2 Dartford Heath junction. Dartford and Bexley town centres are approximately two and three miles away respectively. Activities include bingo and games, crafts, entertainers, one to one chats, manicures and pub visits. Current fee charges range from £592 to £895 per week. Additional charges are payable in respect of hairdressing, newspapers, chiropody and escorting residents to appointments. A copy of the latest inspection report is available in the reception hall or by request at the nurses’ station on the ground floor. Wilmington Manor Nursing Home DS0000026214.V338297.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first key unannounced visit to the home for the inspection period 2007/08. Link inspector Elizabeth Baker carried out the site visit. The visit was carried out on the 10 May 2007 and lasted just under eight hours. As well as touring the home, the visit consisted of talking with some residents, staff and visitors and inspecting some records for case tracking purposes. Three residents, four members of staff and two visitors were interviewed in private. Feedback of the findings was provided to the home manager at the end of the visit. A separate pharmacy inspection was carried out on the 14 May 2007. Pharmacy Inspector Jeanette Datoo carried out the visit. That visit lasted almost four hours. The findings of the visit were provided to the home manager and have been incorporated into this report. At the time of completing this report, in support of the visit, the Commission received survey forms and comment cards about the service from one relatives/advocates/visitors and one health care professional. At the Commission’s request the home manager completed and returned a preadmission questionnaire. Some of the information gathered from these sources has been incorporated into the report. At the time of the visit, 47 residents requiring nursing care were residing at the home. Since the last visit, the Commission has been made aware of four complaints made directly to the home and/or to commissioning authorities. What the service does well: Most of the requirements made following the last visit have now been complied with. Following a period of instability due to management changes, there is clear evidence that the new home manager, with support from the provider, is working to improve the service where there are still shortfalls. The home’s admission process tries to minimise any anxieties new residents may have. Special occasions for residents are celebrated. A comment card respondent stated “[Although their relative was only at the home for a short time] the staff were very professional and kind to them during the short period. Their helpfulness and understanding towards our family was faultless”. This certainly is an improvement as regrettably this has not always been the experience of other families, resulting in complaints. Wilmington Manor Nursing Home DS0000026214.V338297.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Wilmington Manor Nursing Home DS0000026214.V338297.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 Wilmington Manor Nursing Home DS0000026214.V338297.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): Standards 1, 3 and 6. Residents who use the service experience good quality outcomes. We have made this judgement using a range of evidence, including a visit to this service. The home’s Statement of Purpose/Service User Guide provide prospective residents with the information they need to make a decision about moving into the home. Usually residents move into the home assured their needs will be met. EVIDENCE: The home has produced a statement of purpose and service user guide document. Following requirements made previously the document has been expanded, providing prospective residents and or their advocates with more information. However the document provided at this visit retained information about the previous registered manager. The new manager said the documents would now be amended. To minimise any anxieties any new residents may have, the home encourages family and or friends to personalise the bedroom to be occupied with small personal bits and pieces. A selection of toiletries and some fresh flowers are also provided as part of the welcoming process. Wilmington Manor Nursing Home DS0000026214.V338297.R01.S.doc Version 5.2 Page 9 Where practicably possible, prospective residents are assessed by Registered Nurses in their current environment prior to a decision of admission being made. The assessment visits determine whether the home can actually meet the assessed needs of the particular resident. If this is the case, the information gathered at the visit, is used to inform the resident’s care plan. Where a local authority or primary care trust sponsors a prospective resident, information is also obtained from these sources. The home is not registered for intermediate care. Standard 6 is not applicable. Wilmington Manor Nursing Home DS0000026214.V338297.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): Standards 7, 8, 9, 10 and 11. Residents who use the service experience adequate quality outcomes. We have made this judgement using a range of evidence, including a visit to this service. Although the maintenance of resident’s care records has improved they still do not provide clear evidence of care planned and that delivered. Not all residents know that their personal wishes and preferences will be met. Not all personal care and support is offered in a way to protect residents’ privacy and dignity. EVIDENCE: Since the last visit new care documentation has been introduced. It is anticipated that all residents will have been provided with the new model by the end of May. The care records inspected were all of the new model. The documents had not in all cases been completed as intended and did not provide a coherent picture of care needs assessed, that planned and that delivered. In one case no account had been taken of the residents’ preferences to use a particular bathroom and frequency of baths. The resident has expressed these matters to former managers and staff on numerous Wilmington Manor Nursing Home DS0000026214.V338297.R01.S.doc Version 5.2 Page 11 occasions. Indeed current care staff know of this, but still do not provide this level of care. This aspect of care might seem insignificant to some staff, but is important to the resident. The new manager was unaware of the matter. Where risk assessments were in place to monitor the effectiveness of the treatment plans, these were not always accurate of the resident’s current condition and abilities, even though the assessments had been regularly reviewed. A new pressure sore risk assessment was incorrect. Pressure sore risk assessments were not always supported by an anticipated wound care plan. Where pain has been identified as a problem care records contained a pain assessment chart and site map. The organisation has recently published and provided all homes with new bed rail assessments. The document was seen in the records inspected. However in one case the former 2003 version was also in place. The handwriting seen in care records on the ground floor was difficult to decipher. Indeed the head of care acknowledged this was a known problem. The daily records seen on both floors did not provide for a complete picture of the residents’ day. Some meaningless statements are used as evidence of the care provided. These included “self-caring”, “duly cared for” and “all care needs met”. As some of the care records contained limited care plan information, these statements if required as evidence of actual care delivered may prove difficult to justify. The new care records contain a form inviting input from the resident and or relative/advocate in compiling the individual care plan. Where the form had been used, it was for the wrong purpose. In cooperation with the GP and supplying pharmacist, the home had changed to a monitored dosage blister pack system for medicines. Training had been arranged for the nurses. The temperatures of the one medicines storage room and the fridge are monitored and within the correct range. The manager agreed that the temperature of a second storage room would be monitored. A Schedule 3 controlled drug was not stored appropriately, which the manager agreed must be done and that additional records would be kept. A new stock control system was in use for medicines not prescribed regularly every 28 days. Examples were seen of weekly and monthly medication audits. Records of receipt, administration and disposal of medicines were clear. There was a list of nurses who administer medicines with sample initials. A nurse said that carers applied some creams but nurses monitored this. Another nurse said that it had been agreed to put additional information, with medication administration record charts, about the use of medicines to be taken ‘as required’. This had not been done but the manager said that this would be done by 10 June 2007. A log of dates of medication reviews was seen. All bedrooms are for single use and have ensuite toilet facilities. Residents’ communal toilets are also available around the home. For privacy purposes toilet doors are lockable. However a resident was seen using a toilet with the door left open. The room looked out onto a corridor. A comment card respondent indicated “the doctor visit is not confidential for each resident”. Wilmington Manor Nursing Home DS0000026214.V338297.R01.S.doc Version 5.2 Page 12 Indeed residents’ consultations with a doctor in communal areas were seen at the visit. The new documentation requires details of resident’s spiritual and cultural wishes and preferences in respect of death and dying to be recorded. However not all the information has yet been transferred to the new documentation and is still retained on records composed in September 2006. These records require monthly review. There was little evidence this was being done. This is disappointing as the Commission is aware of a complaint made to the home concerning palliative care. Wilmington Manor Nursing Home DS0000026214.V338297.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): Standards 12, 13, 14 and 15. Residents who use the service experience good quality outcomes. We have made this judgement using a range of evidence, including a visit to this service. The home provides a range of activities. However this does not guarantee that all residents’ receive the stimulation and occupation of their preferred choice. Meals and menus have improved, although not to all residents’ complete satisfaction. EVIDENCE: Residents are provided with an information pack, which is kept in their rooms. This includes details of the home’s facilities, how to make a complaint, menus and a newsletter informing residents of forthcoming events and activities. Residents are able to choose how to spend their days and some choose to spend this in the privacy of their own bedrooms – reading, writing, watching the television or listening to the radio. The home’s activities coordinator arranges entertainment and occupation, as well as providing one to one support where this is a preferred option. A minister visits the home on a weekly basis to facilitate a Holy Communion service. This is important to some Wilmington Manor Nursing Home DS0000026214.V338297.R01.S.doc Version 5.2 Page 14 residents. Despite this one resident reported the “days are long and can be boring”. Visiting times are open and visitors were seen coming and going throughout the inspection. The new care documentation includes a “map of life”. The purpose of this is to obtain biographical information about residents, which should assist the home in organising activities to meet the diverse needs, expectations and abilities of all residents. The home recently facilitated a special party and entertainment for a resident’s 100th birthday. Relatives, visitors, other residents and staff were all invited to celebrate the event. Residents have the choice of eating their meals in one of the two dining rooms or in the privacy of their own rooms. There were mixed responses from residents about the meals. These included “excellent meals, although sometimes the meat is tough but the soups are gorgeous”; “food is reasonable, but take or leave it, as the food does not always suit me”; “meals not that great as prefer plain food” and “more choices now”. Residents taking their meals in the dining room are given one course at a time. It was noted on this visit that residents taking their meals in their rooms are given all courses together on a tray. This may reduce the resident’s enjoyment of the dessert if it happens to be a hot choice – which it was on the day of the visit. Wilmington Manor Nursing Home DS0000026214.V338297.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, 17 and 18. Residents who use the service experience adequate quality outcomes. We have made this judgement using a range of evidence, including a visit to this service. Formal complaints are investigated. However not all residents feel they are listened to and their “complaints” acted upon. EVIDENCE: The provider’s complaint’s procedure is prominently displayed in the reception hall. A copy of the procedure is contained in the information book provided in each bedroom. Residents and visitors spoken with knew what to do if they had a complaint. Indeed one visitor said any concerns the family have had the new manager has put right. Although the Commission has not directly investigated any concerns about the home since the last visit, the Commission is aware of four complaints and or concerns, which have been investigated by the Provider and or commissioning authorities. The home maintains a complaints record. However this did not reflect all the concerns made known to the Commission. It is not the home’s practice to centrally record concerns or niggles expressed by residents. As already stated, during this visit a resident again reported that they do not receive all aspects of their care as per their preferred choice. This is despite the matter being discussed with two former managers. The new manager was unaware of the problem. Recording centrally all niggles and adverse comments, as well as formal complaints, may improve the home’s quality assurance process. Wilmington Manor Nursing Home DS0000026214.V338297.R01.S.doc Version 5.2 Page 16 Arrangements are in place for residents to vote in elections if they wish to. Staff interviewed described appropriately the action they would take if they had a suspicion of adult abuse. Wilmington Manor Nursing Home DS0000026214.V338297.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, 20, 21, 23, 25 and 26. Residents who use the service experience good quality outcomes. We have made this judgement using a range of evidence, including a visit to this service. Generally, the standard of the environment used by residents is good, but redecoration of some doors and walls in corridor areas would enhance the home for resident’s enjoyment. Infection control risks could be minimised if sluices, laundry and some toilets were kept in a tidier and or better decorative state, allowing for more effective cleaning. EVIDENCE: Since the last visit the maintenance person has left. A new person has been appointed and is currently being supported by maintenance staff working at nearby associated homes. Although the general environment of the home is satisfactory some areas are starting to look a bit worn. This was evident in some corridors, where doors, skirting boards and walls had been damaged by equipment contact. A health and safety committee meeting was held at the home on 23 February 2007. This included the statement that magnetic door Wilmington Manor Nursing Home DS0000026214.V338297.R01.S.doc Version 5.2 Page 18 closers are to be placed on bedroom doors. This should improve the home’s fire safety precautions. The fire safety officer of the local authority carried out a fire safety audit of the home last year. The home manager said requirements and recommendations made have now been completed. In one of the sluice rooms a ceiling tile was missing. The room has a mechanical machine. The fire integrity of the room may now be compromised. Areas used by residents were clean and odour free. However the sluice rooms were untidy, cramped and stuffy; the laundry still has a damp problem, the floor sealant in a particular WC was missing and an ensuite room was being used to store excess boxes of incontinence pads and special feeds. This situation may prevent effective cleaning, potentially placing residents at risk of cross infections. Door handles on some WCs are broken which may present difficulties for users in ensuring their privacy and dignity is maintained. For residents’ and staff safety, the home has a range of lifting and moving equipment. All rooms used by residents are connected to the nurse call system. Adjustable beds are provided to residents’ on an assessed needs basis. The home has its own range of pressure relieving and preventative equipment and intends to acquire more. This is important, as primary care trusts are no longer automatically providing this special equipment when there is an assessed need. Wilmington Manor Nursing Home DS0000026214.V338297.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): Standards 27, 28, 29 and 30. Residents who use the service experience good quality outcomes. We have made this judgement using a range of evidence, including a visit to this service. Recruitment policies are followed resulting in residents receiving care from appropriately vetted staff. EVIDENCE: In addition to care staff, staff are employed for cooking, cleaning, laundry, activities, maintenance, administration and reception. Care staffing levels generally follow the guidance issued by the original regulatory authority when the home was first registered some years ago. Staff were seen carrying out their duties in an unhurried manner. Residents indicated staff response to answering the call bell is “not bad” and “sometimes I have to wait too long to go to the toilet”. The new manager acknowledged there had been occasions at the beginning of the year when the home run below the usual levels. 34 of untrained care staff are now trained to NVQ level II. This is a decrease since the last visit. There is an expectation that at least 50 of unqualified care staff would have now achieved this qualification. The returned PIQ indicates that since the last visit, care staff have received training in administration of medicines, Quest documentation, skin care, syringe driver, skills for care, intermediate health and safety and moving and Wilmington Manor Nursing Home DS0000026214.V338297.R01.S.doc Version 5.2 Page 20 handling updates. Notice boards around the nurses’ stations, included details of future clinical training being facilitated by external trainers. Topics include pressure ulcer care, chronic oedema and palliative care. In the main, staff files are maintained to a good standard and allowed for easy auditing. New staff are vetted for past experience, integrity and suitability to work at the home. New staff are required to undertake in-depth induction programmes. The induction programmes follow the Skills for Care specifications. A carer commented that the amount of training available is important to them as they would like to develop their skills and undertake nurse training in the future. Wilmington Manor Nursing Home DS0000026214.V338297.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, 32, 33, 35, 36, 37 and 38. Residents who use the service experience good quality outcomes. We have made this judgement using a range of evidence, including a visit to this service. Although the running of the home has much improved, the new manager is fully aware of what still needs to be done to improve the home further. EVIDENCE: The new home manager has been in post for about four months. The home manager is suitably qualified, managed an associated nursing home for about 11 years and has over 20 years management experience of caring for the elderly. The manager has applied to the Commission to become the registered manager of the home. Residents, staff and visitors spoken with were complimentary of the new manager and management style. Wilmington Manor Nursing Home DS0000026214.V338297.R01.S.doc Version 5.2 Page 22 Since the last visit a residents’ satisfaction survey has been carried out on behalf of the Provider. The results are available on request from the home manager. Regular staff meetings are now taking place. A residents/relatives meeting was held in March 2007, although minutes of the meeting were not available. It is anticipated another meeting will be held at the end of June. All care staff receive supervision and registered nurses have their clinical practices observed. Since the last visit the home has been provided with new policies and procedures. These are available at the nurses’ stations and are accessible to all staff at all times. Following a number of complaints made directly to the home about poor care, additional training and support has been introduced. The home is responsible for maintaining the personal allowance of one resident. Appropriate records are maintained. There is a possibility the service will be expanded. However there is currently no information to inform the resident or indeed prospective residents about restrictive access to personal monies out of normal office hours. This information would enhance service. The home has facilities to securely hold items of importance on behalf of residents. A record book is maintained. However in one case the records were not reflective of the current situation. As stated previously some care records were incomplete of pertinent information. While the majority of care and staff files are maintained with due regard to confidentiality, some monitoring clinical charts had been left outside bedrooms in easy access of visitors. The returned pre inspection questionnaire indicates that 12 staff are trained in first aid. The form also indicates that the home’s equipment and appliances are routinely serviced and or checked. Staff interviewed said they had received training including fire, health and safety, moving and handling and infection control. Wilmington Manor Nursing Home DS0000026214.V338297.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 2 3 3 X 3 X 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 2 3 2 3 Wilmington Manor Nursing Home DS0000026214.V338297.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 OP16 Regulation 17(2),Sch 4(11) Requirement All complaints (written, verbal, informal and formal) must be recorded and acted upon. (Timescale 30/11/05 and 30/09/06 not completely met) Care plans must be complete of all assessed problems, needs, wishes and preferences; complied with input from the resident and or advocate if that is the resident’s wish and be regularly reviewed and updated. Schedule 3 controlled drugs that must be stored in a controlled drugs cupboard must be identified and stored correctly. Timescale for action 30/06/07 2 OP7 15(1) and (2) 31/07/07 3 OP9 13(2) 14/06/07 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 home’s Statement of Purpose/Service User Guide must be kept up to date. DS0000026214.V338297.R01.S.doc Version 5.2 Page 25 Wilmington Manor Nursing Home 2 3 4 5 6 7 8 9 10 11 12 13 14 15 OP7 OP8 OP9 OP10 OP10 OP12 OP15 OP15 OP19 OP19 OP19 OP26 OP28 OP35 16 OP37 Daily records must contain meaningful information of the resident’s day. All clinical risk assessments should be completed accurately. The temperature of the smaller medicine storage room should be monitored so that medicines are stored according to manufacture’s directions. Residents should be able to have baths/showers as frequently as per their preferred choice. Residents’ privacy, confidentiality and dignity must not be compromised. The range of activities and occupation for all residents should be reviewed. Menus and choices should take account of all residents’ preferences. Residents should have sufficient time to finish one course before being served the next. Confirmation should be sent to the Commission when action required by the Environmental Health Officer has been completed. All areas of the home used by residents should be kept in a good decorative state. The fire integrity of rooms must not be compromised. Sluice rooms, laundry, ensuites and toilets must be kept in a condition, which allows effective cleaning. 50 of unregistered care staff must be trained to NVQ level II care. Restrictive access by residents to their personal monies should be recorded. Prospective residents should be informed of such restrictions. Safekeeping of valuables records must be kept up to date. All care records must be completed as required in legible handwriting and stored appropriately. Wilmington Manor Nursing Home DS0000026214.V338297.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Wilmington Manor Nursing Home DS0000026214.V338297.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. Re-publishing this information is in breach of the terms of use of that website. 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