Inspection on 06/09/06 for Wilnecote Rest 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 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Wilnecote Rest Home 30/04/07

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 Key Unannounced Inspection 6 September 2006 09:00 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 Wilnecote Rest Home DS0000040806.V306559.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. Wilnecote Rest Home DS0000040806.V306559.R02.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 01827 261569 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.V306559.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2005 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 contained in the pre inspection questionnaire and from verbal discussions with the provider and manager 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.V306559.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was completed with the registered care manager, deputy and staff on duty, residents and visitors. The Commission had received one relatives comment card, there were no additional comments the relative was satisfied with the home. At some stage in the inspection two residents were assisted by the staff to complete a comment form. Comments from one relative and the district nurse will be included. There had been an administrative error by the Commission and the home did not receive the pre inspection questionnaire until the day prior to the inspection. The care manager will complete the document and forward it. A tour of the home was conducted as part of the inspection, residents were spoken with and staff observed. Records, reports and documents were readily made available to the inspector. At the time of this inspection the home had sixteen residents. Two bedrooms in the recently registered part of the home were in use one more had been prepared by the family for their relative. What the service does well: What has improved since the last inspection? Since the previous inspection the home had extended its registration to offer accommodation to eight more people. Wilnecote Rest Home DS0000040806.V306559.R02.S.doc Version 5.2 Page 6 The original lounge has been decorated, new curtains hung and carpet fitted. New dining room tables and chairs had been purchased. The manager had addressed the two of the three previous requirements. Activities and an extended social life had commenced; with external entertainers and staff stimulating the residents. 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. Wilnecote Rest Home DS0000040806.V306559.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 Wilnecote Rest Home DS0000040806.V306559.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): 1,3,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a review of the statement of purpose and pre assessment documents. The recently updated Statement of Purpose included the recently registration and would provide the public with accurate information. The evidence recorded for information gathered prior to an admission was regarded as poor in its content. EVIDENCE: The manager had considered and updated the Statement of Purpose to include the new registration. The Statement of Purpose was displayed in the hall for any person to access. The Service Users Guide was also to be updated and given to families and or residents where applicable. Wilnecote Rest Home DS0000040806.V306559.R02.S.doc Version 5.2 Page 9 A good collection of pamphlets were displayed in the home, it was suggested that perhaps information in respect of the service provided by local funeral directors and the process to follow when registering a death would be helpful. A sample of pre assessment prior to admission in respect of a person health and personal needs was evidenced. The information contained in the documents were extremely poor it contained no relevant information that would enable a positive care plan to be built up, or to ensure that the home could meet the needs of the individual. This was discussed with the care manager at the time. This report makes it a requirement to have preassessment completed to a better standard. Wilnecote Rest Home DS0000040806.V306559.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a sample of the care plans observing the medication system and staff on duty. The care plans sampled were incomplete in parts and required attention to details. The risk assessments recorded could be more descriptive. Medication prescribed for one person should not be administered to another resident. This practice is not conducive to a persons health. The staff on duty were committed to the daily needs of residents and demonstrated good practices of care. EVIDENCE: The sample of the care plans evidenced that they were incomplete and required some attention. There was limited evidence within the pre assessment. The plans did not include the care of residents that had emotional needs. There was no plan that identified one resident’s possible medical Wilnecote Rest Home DS0000040806.V306559.R02.S.doc Version 5.2 Page 11 condition and how to relieve it. Care plans were maintained in folders it might be beneficial if the provider consider a more formal system now the numbers of residents had increased. Risk assessments need to be more proactive considering all aspects of the person daily life style. This report makes it a requirement to review the system, plans and risk assessments. One of the visitors commented to the inspector that on his visits he found the staff polite and friendly, his relative had improved greatly since being in the home. Arrangements were in place for the continued health care of residents. One of the district nurses told the inspector she had no concerns about the follow up care provided by the staff. She was called only when necessary. The medication administration was observed; the staff responsible had received training for the safe handling and administration of medicines. The inspector had concerns that one-persons medication had been reassigned to another person instead of being returned to the pharmacist. This is poor practice and not conducive to a residents health. This report makes it a requirement that the practice is ceased. Staff were observed during the inspection they, addressed the needs of the residents in a sensitive manner, one resident became distressed a number of time during the day she was spoken to with empathy and her concerns addressed. Wilnecote Rest Home DS0000040806.V306559.R02.S.doc Version 5.2 Page 12 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): 12,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including observations of the lunch, speaking to residents in respect of activities. The daily routine and social life for the residents had been evolved to provide appropriate stimulation for the residents. The menus had been reviewed to provide a more varied diet suitable to meet the residents choice. EVIDENCE: There had been a marked improvement in the social life of the residents since the previous inspection. The manager had arranged for external entertainment to visit the home. Residents spoken with told the inspector that they had enjoyed it. There was photographic evidence of the time enjoyed with the majority of the residents dancing with the staff. More entertainment was arranged during the inspection for the Christmas period. The staffs have taken on more responsibility to stimulate residents. One of the new residents was inspiring the staff by teaching them to waltz and foxtrot; this was her particular interest. Wilnecote Rest Home DS0000040806.V306559.R02.S.doc Version 5.2 Page 13 The reviewed menus were not yet operational; the provider had asked a nutritionist to view them. The cook was preparing lunch from the current menus. The lunch was well prepared and an alternative was offered and served to one resident. During the inspection two visitors came to the home who were spoken with both were satisfied with the care their relative received. One person preferred to visit his relative in the quiet room this was respected by the staff who assisted the resident to a comfortable chair. Wilnecote Rest Home DS0000040806.V306559.R02.S.doc Version 5.2 Page 14 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): 16,18 Quality in this outcome area is good. This judgement was made using available evidence including consulting the complaints procedure, speaking with the staff on duty. The homes complaints process was displayed in the entrance hall providing the applicable information to raise a complaint. The experienced staff group protected residents from abuse from training provided. EVIDENCE: The stakeholders, residents and staff had raised no complaints since the previous inspection. The Commission had received no concerns about the home or care provided. Staff spoken with assured the inspector that their awareness and training was current and were aware of the need to monitor and protect the residents from any form of abuse. Wilnecote Rest Home DS0000040806.V306559.R02.S.doc Version 5.2 Page 15 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 23 24 25 26 Quality in this outcome area is good. This judgement has been made using available evidence including a tour of the home and by speaking with residents. The recently registered section of the home was well furnished and maintained. The original part of the home would benefit from some extra makeover to achieve the same standards. There were some areas where infection control should be considered as a priority. EVIDENCE: The recently registered extension has been tastefully decorated the bedrooms in use contained many personal possessions. Following this registration this inspection identified that a small cupboard or vanity unit would be beneficial placed in the en-suite. Wilnecote Rest Home DS0000040806.V306559.R02.S.doc Version 5.2 Page 16 Carpets had been replaced in the large lounge and dining room in the original home, this area had been decorated, and new dining room furniture had been purchased. It was identified that the phone in the new lift was not working; the care manager contacted the appropriate person who will visit. Identified in the original part of the home were some fire doors that would not be effective in the event of a fire, this had been identified following the constant running of the heating system and will be addressed. The manager had advertised for additional housekeeping staff, this was required from the evidence in a minority parts of the home where some evidence of toilets that would have benefited from extra care. Discussed and made a requirement in the previous inspection was the need to provide cover for continence equipment or to leave them in personal bedrooms and not uncovered in toilets. This had not been addressed on the day of this inspection and remains a requirement. The inspector was told that one of the night staff left the pads out as a help to the day staff. This person will be spoken with to ensure that she understands about cross contamination. The home had good standards of hygiene throughout. From the evidence observed in the environment, requirements will be made. Wilnecote Rest Home DS0000040806.V306559.R02.S.doc Version 5.2 Page 17 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): 27.28.29.30 Quality in this outcome area is good. This judgement has been made using available evidence including speaking with residents, staff and reviewing records. There were systems in place to protect the residents from abuse. The agreed staffing levels were in place for the morning of the inspection and were adequate to meet the needs of the residents. Staff demonstrated their competency and ability to address the needs of individuals. EVIDENCE: The provider had agreed to extra staffing to meet the needs of residents this included one extra in the morning and three waking night staff. The care manger was aware of the recruitment of new staff had to comply with the National Minimum Standards. At the time of this inspection one persons police record check had not been returned. Three of the staff records were seen one person was to obtain a character reference, she had not been in work for sometime and the previous firm had closed. Wilnecote Rest Home DS0000040806.V306559.R02.S.doc Version 5.2 Page 18 There were three vacancies, including a part time cook and housekeeper. It is hoped that the care manager will complete the Registered Managers Award at the end of November 2006. Obligatory training was current evidenced from the records made available and from verbal confirmation by the staff. Wilnecote Rest Home DS0000040806.V306559.R02.S.doc Version 5.2 Page 19 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 36 38 Quality in this outcome area is good. This judgement has been made using available evidence including reviewing records and speaking with the staff. The home was operated to the best interests of the residents this was obvious during the observations made during the day. Records evidenced that the residents were protected by the staff awareness for the prevention and procedures in the event of a fire. EVIDENCE: The fire records were current, the majority of the staff had attended the fire drills organised by the manager. Any equipment used by the residents had been serviced under contractual arrangements. Wilnecote Rest Home DS0000040806.V306559.R02.S.doc Version 5.2 Page 20 Electrical “PAT” testing had been completed 2 May 2006. The stakeholder feedback had developed slightly and the three comments received by the manager had been positive. The manger had plans to approach families for written feedback. Staff spoken with confirmed that they continued to receive supervision. Following the last inspection the manager had reviewed the staff records and identified where they did not comply with the National Minimum Standards Schedule 2 the gaps were being addressed. Wilnecote Rest Home DS0000040806.V306559.R02.S.doc Version 5.2 Page 21 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 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X 3 3 3 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 N/A X 3 3 3 Wilnecote Rest Home DS0000040806.V306559.R02.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement Timescale for action 25/10/06 2. OP7 15 3. OP26 13 3 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 25/10/06 The registered person shall ensure that a written care plan is prepared after consultation with the resident or their representative. All their daily needs should be made part of the plan. Risk assessments should be proactive to suit individuals daily life style. Evidence should be maintained as to the involvement of the resident or representative. The registered person shall make 25/10/06 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. This is outstanding from the previous inspection time scale 31/10/05 Only medication prescribed to an individual should be DS0000040806.V306559.R02.S.doc 4 OP9 13(2) 25/10/06 Wilnecote Rest Home Version 5.2 Page 23 5 OP19 13 (4)(c) administered to them. No medication not prescribed to that person must be administered to any other person The registered person shall 25/10/06 ensure that risks to the health and safety of residents are protected at all times. Doors where required should be locked. To ensure that the telephone in the lift is in working order. 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 To consider expanding the information provided in leaflet forms to relatives Wilnecote Rest Home DS0000040806.V306559.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. Extracts may not be used or reproduced without the express permission of CSCI Wilnecote Rest Home DS0000040806.V306559.R02.S.doc Version 5.2 Page 25 - 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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