Inspection on 06/09/06 for Wilmington Manor Nursing Home

This inspection was carried out on 6th September 2006.

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 10/05/07

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 6th September 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wilmington Manor Nursing Home DS0000026214.V305955.R02.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.V305955.R02.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 wakefiep@bupa.com www.bupa.co.uk BUPA Care Homes (CFCHomes) 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) Mrs Patricia Anne Wakefield 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.V305955.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 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. Current fee charges range from £550 to £850 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.V305955.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first unannounced key visit to the home for the inspection period 2006/07. The inspection took place over nine hours and was carried out by lead inspector Elizabeth Baker. The visit consisted of a tour of the premises, inspecting some records for case tracking purposes and talking with some service users, visitors and staff. Five residents, one visitor and three members of staff were spoken with in private. In the absence of the registered manager, one of the provider’s Regional Support Managers provided assistance. Some judgements about the quality of care, life and choices were taken from conversations with residents, visitors and staff, as well as direct and indirect observations. Up to the time this report was compiled, the Commission received comment cards about the service from residents (3), relatives/advocates (2), GP (1) and Health Care Professional (1) and covered the period from the last visit to the current visit. At the Commission’s request the provider completed and returned a pre inspection questionnaire. Some of the information gathered from these sources has been incorporated into the report. At the time of the visit 49 residents requiring nursing care were residing at the home. What the service does well: What has improved since the last inspection? Many requirements and recommendations made following the last visit have been complied with. To ensure better liaison between GPs and the home, a new care coordinator role has been instigated. The home’s statement of purpose has been improved, although further clarification of a number of points is still required. Wilmington Manor Nursing Home DS0000026214.V305955.R02.S.doc Version 5.2 Page 6 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. Wilmington Manor Nursing Home DS0000026214.V305955.R02.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.V305955.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 6 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The home’s current statement of purpose may inadvertently mislead prospective residents and their advocates about the home’s actual registration categories. EVIDENCE: Since the last visit, the home has further enhanced its Statement of Purpose. However it is still not totally reflective of the home’s actual registration in that the home is not registered for dementia care. This point is not made clear. The review of a number of care records identified dementia as part of the residents’ overall condition. In one case this condition was mentioned in assessments from other professionals involved in the admission process. Admitting out of category residents could result in regulatory action being taken. The regional support manager said arrangements had already taken place to transfer a number of residents assessed as requiring dementia care to another appropriate home. One of the regional support managers said sponsored residents are now being provided with terms and conditions of staying at the home. Previously only Wilmington Manor Nursing Home DS0000026214.V305955.R02.S.doc Version 5.2 Page 9 privately funded residents had this. However three returned comment cards from residents indicated they had not received a contract. Prospective residents are normally assessed in their current place of abode, prior to a decision of admission being made. The home’s manager or representative carries this out. A comment card received from a relative/advocate after the previous visit included comments about staff not being appropriately trained to care for residents with Multiple Sclerosis (MS). There are a number of residents at the home with this condition. Training provided at the home during the last 12 months has not included MS. Indeed a registered nurse said she has never received such training. Standard 30 refers. A newly admitted resident stated they had brought their wheelchair into the home with them. The resident said the wheelchair in use was not theirs and they could not say where their own wheelchair had gone. The resident’s care records included a property list. The list was incomplete and did not inform the reader whether a wheelchair had indeed been brought into the home or not Standard 37 refers. The home is not registered for intermediate care. Standard six is not applicable. Wilmington Manor Nursing Home DS0000026214.V305955.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Care records are not wholly reflective of residents’ complete care needs and preferences, potentially placing them at risk. EVIDENCE: Five care records were inspected as part of the case tracking process. All the residents had been provided with a care plan and associated clinical risk assessments, including nursing admission, tissue viability, falls, moving and handling and nutrition. Environmental risk assessments are also undertaken and the findings recorded in the individual files. Signed consent forms for flu vaccination; homely remedies; photographs and bedrails were seen. However some forms where incomplete of all fields and prompts. One resident had recently had input from a specialist nurse. The information had not triggered a review of the resident’s care plan or indeed a review of the pressure relief and/or preventative equipment. A number of residents were taking variable dose analgesics on an “administer when require” basis. Their care plans did not contain precise administration details. Not all the plans were accompanied by pain assessments, to monitor the effectiveness of the treatment. For a Wilmington Manor Nursing Home DS0000026214.V305955.R02.S.doc Version 5.2 Page 11 resident who requires glasses to improve their general sight, there was no mention of this need in the corresponding plan. The resident was provided with new glasses on the day of the visit and had been waiting for these for some considerable time. In another case reference to a resident requiring their glasses, was seen displayed in a particular bedroom. The resident’s relative had put the notice up as a reminder to staff of this care need. It could not be established in another case whether or not a resident with a high skin integrity risk had been provided with appropriate pressure relief equipment on admission. The equipment is now in situ, although the date when it was provided could not be determined. Where documents did state pressure relief equipment is provided, the actual type is not always recorded. Since the last visit the role of care coordinator has been introduced. This identifies a named registered nurse who is responsible for liaising with GPs and other clinicians throughout the shift. This is good practice and timely, as a returned comment card from a GP indicated the home does not always work in partnership with them; there is not always a senior staff member to confer with; staff do not demonstrate a clear understanding of the care needs of residents; and specialist advice is not always incorporated into the care plan. Daily records are maintained on all residents. However they do not provide for a meaningful description of each resident’s quality of day. Visitors of a newly admitted resident spoke enthusiastically of being invited to the home to discuss their relative’s draft care plan with staff to make sure it is relevant. The home has a clinical room in which medicines and nursing aids and equipment are securely and hygienically stored. Records are kept of the room and refrigerator’s temperatures, to ensure medicines are stored in accordance with manufacturer’s instructions. A review of some limited life eye drops identified one application was still in use despite it being time expired. Although the room was clean, the light diffuser was noted to contain lots of dead insects. Since the last visit registered nurses have been provided with a medicine action plan. Despite this, precise details of variable dose medications are not always recorded on the respective medication administration record chart. A resident reported that following the last visit they had been offered baths more frequently. However this offer has now reverted to once a week. Another resident spoken with said they had not had a bath for over a week and had no idea why. A care record inspected included the comment “offer bath at least once a week”. Residents should be able to have baths as often as they require them. The home has a hairdressing room and residents said this allows them to have their hair done regularly. A resident said the home’s laundry service is excellent – clothes taken in the morning and returned to cupboards in the evening. Some files contained a dying and emergency procedure form. However this does not provide staff with all the information required in respect of the Wilmington Manor Nursing Home DS0000026214.V305955.R02.S.doc Version 5.2 Page 12 resident’s specific spirituality preferences and wishes in respect of death, dying and last rites. A new form has recently been introduced by one the regional support managers to record this information and this was seen in one of the files inspected. Sadly the information was incorrect and incomplete. Wilmington Manor Nursing Home DS0000026214.V305955.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Residents are offered a good choice and variety of meals. Residents are kept informed of events and activities, helping them to make informed choices of how to spend their time. EVIDENCE: Residents are provided with weekly activity programmes, as well as quarterly newsletters. A resident described how much they enjoyed the summer fete. Some residents prefer to stay in their own rooms to read or watch or listen to programmes of their own choices. A number of residents were seen sitting in the garden talking with their visitors. A resident said their visitors can visit at any time and are offered refreshments. However none of the three returned comment cards from service users indicated there are always activities arranged by the home that they can take part in. Bedrooms visited had been individualised with personal effects and made them homely for residents to live in. Menus provided in support of this visit recorded a varied and appetising selection. Residents are able to choose where to eat their meals as the home has two dining rooms. Although at the visit residents were generally complimentary about their meals, none of the three returned comment cards Wilmington Manor Nursing Home DS0000026214.V305955.R02.S.doc Version 5.2 Page 14 from residents indicated they always like the home’s meals. Although meals were not observed during this visit, an appetising aroma permeated around the home at lunch and suppertime. Details of meals provided to residents, which do not appear on the normal menu are now recorded in a diary. However, this could present problems if an investigation into poor care was carried out as the diary is also used to record staff information. Wilmington Manor Nursing Home DS0000026214.V305955.R02.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Not all residents and or their advocates can be assured their complaints will be taken seriously and acted upon. EVIDENCE: The pre inspection questionnaire form indicates there has only been one complaint. A returned comment card from a relative indicated the respondent had complained about their relative’s care on more than one occasion. During this visit a visitor and a resident said they had made verbal complaints about some matters. The complaints book did not contain this information. Only one of the three returned comment cards from residents indicated they knew how to make a complaint. The provider takes appropriate action, when adult abuse is suspected. The returned pre inspection questionnaire indicates some staff have received adult abuse training during the past 12 months. Wilmington Manor Nursing Home DS0000026214.V305955.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The standard of the environment is good providing residents with an attractive and homely place to live. EVIDENCE: New carpets were being laid on the first and second floors at the time of the visit. The home was found to be clean, tidy, warm and odour free. Although the gardens leading from the dining room were in a good state, the enclosed patio area seen from a number of bedrooms was poor. Since the last visit an environmental health officer of the local borough council, as well as an officer of Kent Fire and Rescue Service have inspected the home. Action was required from both inspections. The maintenance man said apart from one item, the fire safety matters have been adhered to. The provider is now required to advise the Commission when full compliance of all the fire safety and environmental health matters has been completed. Wilmington Manor Nursing Home DS0000026214.V305955.R02.S.doc Version 5.2 Page 17 The home is kept in a good decorative state. There are two lounges and two dining rooms for residents to choose from. The small dining room is also available for residents to meet their visitors in private. All bedrooms are for single occupancy and have ensuite WC facilities. The home provides a range of baths and showers to meet residents’ individual preferences. All rooms used by residents are connected to the nurse call system. During a conversation with a resident, the call bell was noted to be out of the resident’s reach. The resident required assistance and had been calling out. The resident’s care records states “ensure bell is within reach”. The buzzer was noted to be dirty. Adjustable beds are provided on an assessed needs basis. Lockable facilities were seen in bedrooms visited. This allows for the safe storage of medicines or small items of importance. The home has two dedicated sluice rooms. A member of staff said they usually have sufficient protective clothing (aprons and gloves) to carryout their duties. A member of staff was seen carrying out a procedure without protective gloves. This practice places the staff member and residents at risk of potential cross infections. The laundry is appropriately equipped to ensure residents’ clothing is maintained to a good standard. A resident was complimentary of the laundry service. Wilmington Manor Nursing Home DS0000026214.V305955.R02.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The home is well staffed, although availability is sometimes lacking. The arrangements for induction are good with staff demonstrating a clear understanding of their roles. EVIDENCE: In addition to care staff, staff are employed for catering, activities, cleaning, laundry, administration and maintenance. A record of staff on duty is maintained and demonstrates the home is staffed 24 hours a day. Despite this two of the three returned comment cards from relatives/advocates indicated in their opinion there are not always sufficient staff on duty. One respondent added “main lounge often not supervised and staff sometimes hard to find”. Residents spoken with said they do not generally have to wait long for staff to respond to the call bell buzzer. However one resident remarked that “night staff are quicker even though there are not so many of them” and another said, “my buzzer has been ignored on occasions and I complained to the manager about this”. None of the three returned comment cards from residents indicated staff are always available when they need them. The returned pre inspection questionnaire indicates 38 of unqualified staff are now trained to NVQ level II care. Wilmington Manor Nursing Home DS0000026214.V305955.R02.S.doc Version 5.2 Page 19 Three staff files were inspected. Systems are in place for recruiting and appointing staff, including obtaining references. One reference obtained contained a different address to that described in the application form and reference request letter. The application form in use requires the applicant to state ten years employment history. In one case there was a gap between 1985 and 1997. Current legislation requires a complete history is stated. For an overseas member of staff, correspondence from the Home Office was seen. However the letter was dated 12.10.03 and related to the employee’s employment with Guy’s Hospital. The Commission’s InFocus document “Safe and sound? Checking the suitability of new care staff in regulated social care services” (June 2006) may provide the home with useful recruitment information. This document is available from the Commission’s website – www.csci.org.uk. The files also contained evidence of induction, recent training and that supervision is carried out. Although the home is not registered for dementia care, the pre inspection questionnaire form indicates staff have received training for this condition during the last twelve months. Disappointedly there was no evidence staff have received training for residents with other conditions that fall under its registration general nursing OP category, namely MS, diabetes, Parkinson’s and epilepsy. The registered nurse interviewed she would like to receive training in these conditions. Wilmington Manor Nursing Home DS0000026214.V305955.R02.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The regional support managers have a good understanding of what needs to improve in the home and are actively striving to achieve this. EVIDENCE: The registered manager is appropriately qualified and experienced for the position. Because of the registered manager’s absence, two regional support managers are running the home on a temporary basis to cover the management responsibilities. Whilst some residents expressed anxieties about the current situation, other residents said the managers are very approachable. Residents and advocates had been informed of the current interim arrangements. Wilmington Manor Nursing Home DS0000026214.V305955.R02.S.doc Version 5.2 Page 21 This visit coincided with a financial audit being carried out by one of the provider’s senior financial administrators, as part of the home’s quality assurance programme. A staff member said they have supervision, attend regular staff meetings and are encouraged to voice their views. The provider annually surveys residents and their advocates for views and opinions on the service provided by the home. The results are collated and an analysis of the findings sent to the home. The pre inspection questionnaire indicates the home has a range of policies and procedures. However some of these have not been reviewed for some considerable time, and in two cases not since 1998. The home is currently responsible for maintaining personal monies on behalf of one resident. Appropriate records are kept. It was established on this visit that current accessibility arrangements could prevent the resident accessing their money, if required, out of normal working hours and weekends/bank holidays. Restricted access is not mentioned in the service user guide. Including this would enhance the current provision. As previously stated, not all records relating to residents have been completed, as the documents require. The returned pre inspection questionnaire records that the home generally ensures its equipment is serviced and maintained as per the manufacturer’s requirements. A separate fire safety inspection and environmental health inspection were carried out on the 7 June 2006 and 1 August 2006 respectively. Fire safety matters and food safety issues were not re-inspected on this occasion. The pre inspection questionnaire indicates 12 members of staff hold a current first aid certificate. The form also records staff have received core training in subjects including fire training, manual handling, health and safety and food hygiene. Wilmington Manor Nursing Home DS0000026214.V305955.R02.S.doc Version 5.2 Page 22 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 2 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 3 3 3 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 3 2 3 Wilmington Manor Nursing Home DS0000026214.V305955.R02.S.doc Version 5.2 Page 23 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 OP1 Regulation 17 Requirement The statement of purpose must be reflective of the home’s current registration criteria. (Timescale 31/03/06 not completely met) A record of all meals actually provided must be maintained. (Timescale 31/05/05 and 30/11/05 not totally met) All complaints (written, verbal, informal and formal) must be recorded and acted upon. (Timescale 30/11/05 not met) Timescale for action 31/10/06 2 OP15 16 31/10/06 3 OP16 17(2),Sch 4(11) 30/09/06 4 OP25 23 5 OP29 19 All rooms used by residents must 31/10/06 be approximately heated for their needs and preferences. (Timescale 15/12/05. Unable to check on this visit) Complete employment histories 30/09/06 must be obtained and any gaps or discrepancies investigated. (Timescale 31/12/05 not totally met) New residents must only be admitted in accordance with the home’s current registration DS0000026214.V305955.R02.S.doc 6 OP4 14 15/10/06 Wilmington Manor Nursing Home Version 5.2 Page 24 7 OP7 15 criteria. Residents’ care plans must be kept up to date to reflect the residents’ current assessed needs and wishes. 30/09/06 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 OP7 Good Practice Recommendations Care plans should be complete of all details relating to residents individual needs and wishes, including frequency of baths. Residents’ daily records should provide a holistic picture of their day. All clinical risk assessments should be complete of all information. Administration of when required medication and variable doses to be completely and accurately recorded. Medicines must not be administered after the manufacturer’s use by date. Pain assessments should be used to monitor the effectiveness of pain relief treatment plans. Light diffusers in the clinical room should be kept clean. Residents should be able to have baths/showers as frequently as per their preferred choice. Care records should be complete of details of resident’s individual wishes and preferences in respect of death, dying and last rites. Confirmation should be sent to the Commission when action required by the Fire Safety Officer and Environmental Health Officer has been completed. Nurse call buzzers should be kept clean to prevent cross infection. Staffing levels should reflect the current assessed needs of all residents. 50 of unregistered care staff must be trained to NVQ level II care. Care staff should receive up to date training to reflect the care needs of current residents, in line with its current DS0000026214.V305955.R02.S.doc Version 5.2 Page 25 2 3 4 5 6 7 8 9 10 11 12 13 14 OP8 OP8 OP9 OP9 OP9 OP9 OP10 OP11 OP19 OP26 OP27 OP28 OP30 Wilmington Manor Nursing Home 15 16 OP34 OP37 registration category. Restrictive access by residents to their personal monies should be recorded. Prospective residents should be informed of such restrictions. Care records should be completed as required. Wilmington Manor Nursing Home DS0000026214.V305955.R02.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: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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