Inspection on 30/04/07 for Wilnecote Rest Home

This inspection was carried out on 30th April 2007.

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

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

Other inspections for this house

Wilnecote Rest Home 06/09/06

Wilnecote Rest Home 25/10/05

Wilnecote Rest Home 15/06/05

Wilnecote Rest Home 06/12/04

Wilnecote Rest Home 01/06/04

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

CARE HOMES FOR OLDER PEOPLE Wilnecote Rest Home Manor Farm Hockley Road Wilnecote Tamworth Staffordshire B77 5EA Lead Inspector Mrs Wendy Grainger Unannounced Inspection 30 April 2007 10:30 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 Wilnecote Rest Home DS0000040806.V338024.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. Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wilnecote Rest Home Address Manor Farm Hockley Road Wilnecote Tamworth Staffordshire B77 5EA 01827 262582 F/P 01827 262582 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) Dr Rais Ahmed Rajput Mrs Nichola Jayne Thomas Care Home 23 Category(ies) of Dementia - over 65 years of age (23) registration, with number of places Wilnecote Rest Home DS0000040806.V338024.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: Located off a busy main road Wilnecote is set in a quiet road within walking distance of a small selection of shops. The home was registered in December 2002 and provided accommodation for fifteen older people suffering with dementia. With the exception of two bedrooms on the first floor in the main house bedrooms were on the ground floor. If necessary the first floor could be accessed via the shaft lift or main stairs. No en-suite facilities were provided, bathing and toilets were located on the first and ground floor. There was very limited parking facilities in the front courtyard to the home a larger parking area is located at the rear of the home. The area at the side of the home at this time was unsuitable for the service users to use. The provider had plans to redesign this area. One large lounge and a quiet lounge were available to all the service users and or their families. The dining room was located off the main lounge. The home has recently been re-registered to accommodate twenty-three older people with a dementia. The home has been interlinked to the external building, which will accommodate eight residents. Each of the new bedrooms had an en-suite facility; bathing and toilet facilities were provided on both floors. From the information provided during discussions with the registered care manager, formal documentation had not been received prior to the inspection; the current fees were from £359-£388, additional costs would be Hairdressing cut £5 (male) cut & set £10 (females) perm £25 Chiropody private £10 and any personal toiletries. Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was completed with the registered care manager, staff and residents on the 30 April 2007. At the time of this inspection there were eighteen residents at Wilnecote. The Annual Quality Assurance Assessment tool was not used on this inspection and will be reflected in the next inspection later in the year. Records, documents and reports were made readily available to the inspector. A tour of the home was made in the company of the deputy care manager. Residents were spoken with during the time spent in the home. Observations made of the interaction between the staff and residents were part of the inspection. The Commission had received no written comments from other professionals, families or residents. Four residents were able to make verbal comments to the inspector; each one was very satisfied with the care they received. “its good here” “I like the girls” They were aware of who to speak to if they had a problem. The interaction between the day staff in particular who were observed for a longer period was warm, respectful and with a genuine empathy of each individuals need. What the service does well: The refurbished part of the home continues to maintain a good quality; it was tastefully decorated. The staff on duty were observed to respond to each individual resident, they had a warm and respectful approach. They demonstrated their knowledge of daily needs; emphasised and addressed any short conflict between residents. The majority of the staff had been employed for a number of years and were professional in their attention to personal care. The registered care manager was part of the working team and on the weekly rota thus ensuring she kept up to date with the needs of the residents. Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 6 Each of the residents seen and spoken with were well presented, some have the ability to make a personal choice, others rely on the staff for guidance. They told the inspector “the girls were good you can have a laugh” I know who to tell if I don’t like something” Residents were free to exercise their autonomy by walking around the home each were encouraged to take calculated risks in their daily routine. The care manager has always been responsive to advice given, during an inspection. The Commission or registered care manager had received no complaints, concerns or allegations. Since January 2007 the staff and management had undertaken four fire drills including the night staff in the training. What has improved since the last inspection? Since the previous inspection the older gas fire in the main lounge has been removed and replaced. The re-decoration of this area is planned for the week of the inspection. New bed linen, curtains, for three bedrooms were on order, continuing the redecoration of the existing part of the home. The provider had purchased a large industrial washing machine since the previous inspection; programmes included a sluice facility. No new staff had been employed, the manager told the inspector she was waiting for police clearance and references for three people prior to employment. The staff employed remained consistent in their approach to the care of the residents. The manager had addressed the requirement in respect of a medication problem identified on the previous inspection. Digital locks had been fitted to the exit fire doors, advice has been sort since the inspection from the fire officer (see report) The home had invested in staff training, records evidenced that all the mandatory training was current or on going. It is hoped that by the end of the year 100 of the care staff will have achieved NVQ in Care level II. Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 7 What they could do better: The previous inspection report identified five requirements one of which was outstanding from a previous inspection in 2005. There remained three outstanding requirements in this report. The toilets located near to the office continued to contain continence equipment left uncovered and subject to cross contamination. This situation was further established when a loose toilet roll was identified to have dried faeces around the roll. It was suggested to the care manager who told the inspector she had discussed this with the night staff who appear to be responsible; that a notice be put up until they refrain from putting residents at risk. This was completed before the end of the inspection. While the night staff were understood to continue with this practice the day staff condone it by not removing them at the commencement of duty. This is outstanding from 2005 The assessment format remains the same, the documents limited evidence and in some cases the form is not appropriate to ensure the home can meet all the needs of the client group. To be fair to the manager she had not used the document since the previous inspection in September 2006, but had done nothing to develop and ensure the document was suitable for its purpose. This is outstanding. The care plans remain in the same format the system continued to lack continuity in the information gathered and recorded following an admission. Four plans were sampled and discussed with the staff; the risk assessments were not pertinent at times and issues recorded in a section not relevant. They continue not to recognise the emotional needs, communication and or aggression of individuals and the action taken to respond to any changes. This is outstanding. At the time of this inspection there had been no alternative prepared for the lunch, when asked the cook told the inspector that she could prepare something such as cheese and potato pie. This practice should be in place without fail. An alternative should always be available to the residents who should be consulted on a daily basis; to meet their likes and dislikes. The freezers seals were dirty and the central freezer had a pink substance down the plastic drawers. A portion of home made pastry was disposed of it contained no date of freezing. A bottle of sea food sauce was given to the manager due to its identified out of date label. Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 8 The records for activities were not accessible, locked in a cupboard and the key retained by the activity coordinator. Within the original part of the home there were a number of concerns raised with the registered care manager. Radiator covers that were original and located at floor level were detached from the wall, these were a potential hazard for residents that chose to walk around the home. The manager told the inspector they had been measured up. It is important that this is dealt with at the earliest possible time. The majority of the beds had “a quantity of lumpy pillows” there was evidence on the weekly shopping list that the care manager had requested pillows two weeks ago; this at the time of the inspection had not been addressed by the provider. It was pointed out to the deputy care manager that two of the beds identified during the tour of the home had been remade by the staff with unacceptable bed linen, which was stained. A minimum of three bedrooms in the original home were in a poor condition of décor with the border either off or peeling off the walls. The care manager told the inspector that the bedrooms had been identified for decoration. Bearing this in mind she had ordered the curtains and bedding. A number of hand towels and flannels were handed back to the registered care manager, due to their unacceptable condition, which was ragged and with little texture left. There was a quantity of new towels in the linen cupboard, which the staff had failed to use. The tap in toilet 9b was loose and would not turn off, there was no soap in this toilet; the toilet seat in toilet 9a was loose and a potential hazard. Used bars of hard soap were handed back to the care manager these were located in the toilets and bathrooms in the home. A number of light bulbs were not working in both lounges; the provider told the inspector that he had a quantity of bulbs. These should be at the home, to ensure the safety of the residents at all times with appropriate lighting. There needs to be monitoring of the seating in the lounge one of the cushions was splitting. The provider informed the inspector that there was a monthly audit of the homes. The other care manager of the sister home and visa a versa undertook this. While the practice of self-auditing the homes is a positive exercise it does not appear to be working, many of these issues identified at the time of the inspection should have been identified and brought to the attention of the provider to address. Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 9 The staff records were identified to be incomplete without the full details required in the National Minimum Standards. This was discussed with the care manager. The above concerns will be reflected in the requirements and recommendations section of this report. Each area was fully discussed with the care manager during the inspection and at feedback. A number of the issues raised were not within her remit to address and were the responsibility of the provider. 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. Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 10 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 Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 11 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 1,2,3, were reviewed. Quality in this outcome area is adequate, This judgement has been made using available evidence including a visit to this service. The Statement of Purpose remained unchanged and provided the relevant and current information about the home. The current pre assessment admission forms remained unchanged and ineffectual for recognising and recording individuals personal and health needs. EVIDENCE: There had been no reason to amend the homes Statement of Purpose since the previous inspection. The document contained sufficient pertinent information providing the public with details to consider making a placement. Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 12 Evidenced from the sampled care plans was that the registered care manager had not reviewed the pre-admission document, which identified on previous inspections did not recognise certain elements to enable the home to judge if the person needs could be met. Each of the residents present at the home were issued with a contract of the terms and conditions of the home, a copy of which should be kept on the individuals file. Wilnecote Rest Home DS0000040806.V338024.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): Standards 7,8,9,10 were reviewed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A review of the documents and records. There was a limitation of information for daily routines, care and calculated risk in the sample of care plans evidenced. The medication system had been reviewed following the previous inspection. Staff had been updated to the previous required changes. The staff observed for the majority of the inspection demonstrated their commitment to the residents. Sensitive to individuals needs and respected the individuals right to exercise choice EVIDENCE: Four care plans were provided at random by the registered care manager. The inspector discussed the care plans with the registered care manager and Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 14 deputy. The previous inspection report made a requirement to review the written information to ensure all elements of care were recorded and relevant to the personal and health care needs of individuals. The plans remain unchanged in detail and information. Of the four plans seen one had no personal photograph, this resident had been at Wilnecote since September 2006. There had been no formal written review of her needs. Recently the resident had occasion and with the agreement of her family moved bedrooms from the first floor to the ground floor. A bed guard was placed on the bed, there was no evidence of a risk assessment or agreement from the resident, family or other professional. The staff had failed to recognise the risk this resident could be at prior to a full assessment of her needs. The staff were unable to monitor one persons weight, this was part of the residents care plan to monitor her health because the homes scales were out of order. Page 5 of the care plan was missing this page was pertinent to the monitoring and addressing any aggression shown by the resident who during the inspection became verbally loud to other residents. This was brought to the notice of the staff during the inspection. The previous review for this residents care plan was August 2006. The management acknowledged that the plans had not moved forward since the last inspection. The risk assessments remained questionable, while residents take calculated risks the staff do not appear to recognise risks that need to be recorded and action to prevent a potential risk. The previous report made it a requirement for the risk assessment to be more proactive. Staff spoken with agreed that the risk assessments had not moved forward in content, layout or detail. The home had arrangements in place for residents to received health care from other professionals. At the time of the visit one general practitioner visited one resident following a referral by the staff. Arrangements were made for the resident to go to the local hospital. The previous concern in respect of medication had been reviewed by the manager and addressed. The home did not use any homely remedies so a protocol was not required. The administration of medication was observed, it was advised that the management review the practice when administering medication to individuals to ensure the safety of other residents the trolley should not be left unattended. Further refresher medication training was planned for the staff. During the majority of the inspection the morning staff were observed to interact with the residents in a warm, professional manner. They demonstrated their awareness of needs and recognised the resident’s choice to walk freely around the home. Staff had empathy and worked on a knowledge basis of individuals needs. The staff addressed any small incident between the residents calmly, they dealt with the admission to hospital professionally, Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 15 providing an escort until the families that had been contacted could arrive at the hospital. Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 16 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 14 15 were reviewed Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents were not offered a choice for the main meal of the day, when no alternative had been prepared. The social activities for residents had been extended, promoting more stimulation for the residents. EVIDENCE: Residents have the option to be part of any social activity, this has over a period of time been expanded to meet individuals life styles and interests. The registered care manager told the inspector that residents enjoyed the Irish dancers. This was evidenced in the written daily reports and from comments made by the residents “the dancers were good and the singers” Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 17 The home now has an activity person; activities take place in the afternoon with the exception of the day of the inspection, which was the person’s day off. It was unfortunate that the records were locked away, kept by the activity person stored within her cupboard. Staff and residents told the inspector that they did things together, the residents had planted seeds, made hats at Easter, which were evidenced in the home. Recently residents had decorated biscuits. Some external entertainment had been arranged with photographs to evidence the session. Visiting to the home was at any time and relatives were welcome to take their relative into the community. There was welcoming banter between the one visitor and staff. The meal of the day was stew followed by apple crumble and custard, the stew was served in a bowl, this was satisfactory for the consistency of the meal, it may have been more appropriate for some residents to be provided with more appropriate cutlery to enable them to cut up the meat. The tea served was sandwiches and small selection of plain salad, followed by fruit flan and ice cream. Staff provided an afternoon cup of tea, there were no saucers given to residents while it was accepted that not all the residents would not be able to manage a saucer. One care plan seen clearly recorded that the resident liked sugar in her tea and a cup and saucer. Further providing the inspector confirmation that the staff work knowledge based and not from the written care plans. The cook when asked had not prepared an alternative for the lunch, she could in hindsight prepared a light salad, or cheese and potato pie from the potatoes left over. It appears that no resident had been asked and were not aware of the meal of the day, which was not written on the board. The required food records were current, as were the temperatures for food served and fridge/freezers. A portion of home made pastry? was disposed of from one fridge, no date or identification was evidenced. Despite having a cleaning rota the two freezers seals and the central freezer were in need of cleaning, the freezer had a pink substance down the outside of the drawers. The potatoes in the store need to be elevated off the floor. Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 18 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): Standards 16 18 were reviewed Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Speaking to residents and staff. Residents and public had access to the homes complaint procedure. Residents were protected from abuse via the staff training and their commitment to the care of the residents. EVIDENCE: The home’s manager had received no complaints since the previous inspection. The Commission had received no concerns, allegations or complaints against the home or care provided. Two residents told the inspector that they would know who to go to if they had a problem The procedure to make a complaint to the manager or Commission was displayed in the entrance hall. The details provided and timescale of response was current. Evidenced in the staff records and from discussions with the staff who, confirmed that they had received training pertinent to protect the residents. Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 19 Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 20 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): Standards 19 20 21 23 24 25 26 were reviewed. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. A full tour of the home was completed. A number of issues were evidenced that should have been part of the staff daily routine to provide residents with a comfortable environment. An audit of the home had failed to identify the poor quality of the bed linen. There was a lack of awareness by the staff to protect the residents from a potential infection. EVIDENCE: Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 21 The newer part of the home evidenced that residents continued to live in an area, which had good quality surroundings. One room had a strong mal-odour of urine, the carpet in this room on the first floor required cleaning. The bedrooms had been personalised to suit the tastes and preference of individuals. One of the beds in this part of the home was not acceptable, it was thought that the night staff had remade the bed and left a dirty pillow case and dirty duvet cover. The registered care manager would address this with the night staff. A similar situation was identified in the original part of the home where a dirty sheet had been left on. On a number of beds throughout the home were pillows that could only be described as “lumpy” and not comfortable for the individuals to sleep on. Evidenced on the homes shopping list a fortnight ago was a request for new pillows; this was still to be actioned by the provider. Original ground floor radiators were disengaged from the wall in the small lounge; these were a possible potential hazard to residents that choose to walk about the home. The registered care manager told the inspector measurements had been taken to replace the covers. This needs to be completed as soon as possible. In the interim period the manager should make the room inaccessible to residents. This situation of the radiator off the wall was identified behind the bed in bedroom 24. A number of bedrooms in the original part of the home were in need of decoration they were shabby and parts of the paper borders were ripped or missing. The registered care manager told the inspector that she had ordered curtains, and bed linen ready to go into these rooms following the decoration. One shared room was in the process of re-decoration. A quantity of hand towels and flannels were handed back to the registered care manager due to their poor condition. The linen cupboard contained new towels and the registered care manager could not answer why staff had put the ripped shabby towel on the beds ready for use. One bathroom on the ground floor in the original house was being used for storage; this is a registered facility for residents use and needs to be cleared. The ground floor toilets 9a 9b were observed to have continence equipment on the cistern plus a toilet roll, which was later, evidenced to have what appeared to have faeces on the base. The lack of infection control and putting residents at risk has been a requirement in other reports and will remain in this report. This was part of the feedback to the registered care manager. The provider Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 22 who visited told the inspector that the registered care manager’s he employed conducts a monthly audit of each homes. Within each of the identified toilets one had a loose toilet seat and the other had a loose water tap. A number of light bulbs were not working; this was pointed out to the provider who told the inspector that he would bring in some light bulbs. There ideally should be bulbs at the home to ensure the appropriate light is provided at all times. The inspector did not access the monthly audit, on this visit, issues identified by the inspector should have been identified during the audit. Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 23 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 30 were reviewed Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service speaking to the staff, checking the training records and speaking with the registered manager. Staffing levels appeared satisfactory for the morning shift to meet the needs of the residents. Staff were experienced and knowledgeable to interact and recognise the needs of individuals EVIDENCE: Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 24 The staffing levels on the morning shift was satisfactory to meet the needs of the residents due to an emergency escort due the afternoon shift was one person reduced; this shift was covered by the registered care manager. At the time of this inspection there were three vacancies for care staff, the registered care manager was waiting for documents to confirm the required police checks and references before employment. From the evidence of the records and from contact with the staff mandatory training was current until later in the year. Training in the recognition, and protection of vulnerable adults had been taken in March 2006. Regular contact with a senior practitioner who provides training in the care of people with dementia was maintained. Staff were involved in distance learning training for medication and infection control. It is expected that the staff involved in NVQ training will have completed it by November 2007. When completed Wilnecote will have 100 of the staff qualified level II NVQ in Care. Some of the staff have level III in this qualification. There has been a problem with the registered care manager completing the Registered Manager Award. This has now been rectified and is now on line to complete later this year. Three of the staff files chosen at random by the registered care manager with the exception of one were current. The documents required were discussed with the registered care manager, to ensure the residents were safeguarded. Staff spoke to confirmed that supervision continued their development was part of the discussions. The inspector was aware that the provider and both the care managers meet each Tuesday to discuss the homes. Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 25 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): Standards 31 33 35 38 were reviewed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Reviewing of the relevant records, speaking to the staff. The staff and management recognise and were observed, to met the needs of the residents on the day of the inspection. The staff promotes the health and safety of the residents. Records evidenced were current, policies and procedures were reviewed annually. EVIDENCE: Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 26 The registered care manager had been in post for a number of years, she continues to support her staff on a daily basis. Mandatory training with the staff was her commitment to the home and residents welfare and safety. As part of her knowledge the registered care manager is on line to complete the registered managers award later in the year. The home had recently received an inspection/audit from the local Fire Officer; the registered care manager told the inspector that he was satisfied with the home. The inspector had concerns and had contacted the Fire Officer to ask for clarification in respect of the new digital locks located in the original building and at fire exits. The Fire Officer will check this out with his colleague. Digital locks can be fitted with the agreement and guidance of the Fire Officer and must be linked into the fire system. 4/05/07 contact was made with the fire officer who confirmed that the staff had informed him that the system was connected into the fail safe fire system. Records in respect of the annual fire audit, drills and weekly testing of the system were current. The registered care manager had organised four fire drills since January this included the night staff. The registered care manager was to finish completing the written contingency plans for the home in the event of an emergency. Staff confirmed from discussions that they continue to receive supervision from the management. The registered care manager told the inspector that stakeholder questionnaires had been sent out after Christmas there had been little or no response. Residents spoke well of the staff who responded to them readily meeting their daily needs. It is the homes policy not to retain residents’ personal finances; this is discussed during the admission process with relatives. Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X 3 2 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X N/A 3 X 3 Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 28 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 OP3 Regulation 14 Requirement The registered person shall ensure that a suitable qualified or trained person has assessed the needs of the residents. Information relating to the persons needs should be fully recorded. This remains outstanding 25/10/06 The registered person shall ensure that a written care plan is prepared after consultation with the resident or their representative. Residents daily needs should be made part of the plan, which should be meaningful. Risk assessments should be proactive to suit individuals daily life style. Evidence should be maintained as to the involvement of the resident or representative. This remains outstanding 25/10/06 Timescale for action 02/06/07 2. OP7 15 02/06/07 3. OP26 13 3 The registered person shall make 02/06/07 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. This is outstanding DS0000040806.V338024.R01.S.doc Version 5.2 Page 29 Wilnecote Rest Home 4. OP15 16(i) from the previous inspection time scale 31/10/05. 25/10/06 Residents should have an option 02/06/07 on a daily basis for any meals served. One person prior to the meal being prepared, to ensure a balanced nutritional diet is served, should consult them. To ensure that areas are maintained in an hygienic manner to prevent illness to the residents. The home should be kept clean 02/06/07 and reasonably decorated at all times. Items that were a potential hazard to residents should be audited and concerns addressed. Each area which was devoid of appropriate lighting were a potential hazard to the well being of the residents. The monthly audit of the home 02/06/07 should identify potential hazards such as loose toilet seats and tap (9a/b) Radiator covers were in a poor condition and a potential hazard to the residents and the staff these should be addressed within the given timescale 5 OP24 23 (d) 6 OP21 23 2(b) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP12 Good Practice Recommendations 1. The key to access the records in respect of any social DS0000040806.V338024.R01.S.doc Version 5.2 Page 30 Wilnecote Rest Home 2 3 OP24 OP26 activity should be available to inspection at all times. The monthly audit should include a review of furnishings to ensure it is acceptable and in good repair. The bars of hard soap left in the bathrooms/toilets were handed to the registered care manager this could be another area where cross contamination occurs. There was a need when auditing the home identifying that items that were not beneficial for the comfort of individuals i.e. pillows and towels then these should be replaced; this should be an ongoing assessment 4 OP24 5 OP24 Staff should be made aware that the use of stained and unacceptable bed linen should not be used when making the individuals beds up in the mornings Wilnecote Rest Home DS0000040806.V338024.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. 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