Inspection on 26/02/07 for Wilson Lodge

This inspection was carried out on 26th February 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wilson Lodge 11/06/09

Wilson Lodge 04/07/07

Wilson Lodge 26/09/05

Wilson Lodge 13/04/05

Wilson Lodge 24/08/04

Wilson Lodge 22/04/04

Wilson Lodge 17/12/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Wilson Lodge 16 Augusta Road East Moseley Birmingham West Midlands B13 8AJ Lead Inspector Lisa Evitts Key Unannounced Inspection 26th February 2007 10:00 Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 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 Wilson Lodge DS0000024909.V331452.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 Adults 18-65. 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. Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wilson Lodge Address 16 Augusta Road East Moseley Birmingham West Midlands B13 8AJ 0121 449 1841 0121 449 2926 wilsoncare05@ukonline.co.uk www.wilson-care.com Wilson Care Resources Ltd 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) Mr Malcolm Wright Care Home 36 Category(ies) of Learning disability (36), Mental disorder, registration, with number excluding learning disability or dementia (36) of places Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 36 adults over 30 years and below the age of 65 years - mentally ill persons with learning disabilities That the manager successfully completes the Registered Managers Award (NVQ Level 4 in Care Management) or equivalent by April 2005 26th September 2005 Date of last inspection Brief Description of the Service: Wilson Lodge was purpose built in the 1970’s and commenced operating as a residential home. The registration status changed at a later date to nursing care for up to 36 adults suffering from mental health problems. Residents may also have a learning disability but mental health illness is the primary reason for admission. As well as the registered manager the home employs a nurse manager. The ethos of the home is encouraging and supporting independence of residents. The home is situated within a residential area, close to the city centre and within walking distance of local shops and other amenities. The building is located at the end of a cul-de-sac and provides turning facilities at the front of the home but no off road parking for visitors. Car parking facilities for staff are situated at the rear of the property. The home has ramped access, which enables disabled residents or visitors to easily access the premises and a passenger lift is available inside the home. Accommodation is spread over two floors offering a mixture of single and shared rooms. One bedroom has an en suite toilet. Communal areas include two lounges, a dining room, a smoking room and two small-secluded gardens. The home has two baths and three showers which meet the needs of the residents living in the home. There are dedicated kitchen and laundry facilities on the premises. Corridors are wide and have handrails, which would enable residents to mobilise independently. A hoist and a stand aid are available and pressure-relieving equipment is available for residents who may require this equipment to prevent skin sores. Copies of previous inspection reports are available from the office however it was recommended that a notice is displayed to inform residents and their representatives that the reports are available, so that they have information about the home if required. The current scale of charges for the home is £437 - £865 and this includes the nursing determination contribution. Additional charges include aromatherapy, Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 5 massage, toiletries, chiropody, hairdressing and outings. Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken by two inspectors over seven and a half hours and was assisted throughout by the Registered Manager and the nurse manager. There were 34 residents living at the home on the day of the visit and information was gathered from speaking with residents and staff and from observing staff perform their duties. Care records, health and safety records and staff files were examined. The management of medication was reviewed and a partial tour of the premises was undertaken. Prior to the inspection a pre inspection questionnaire had been sent out to the manager to complete regarding the home, residents, and staff however this had not been returned to CSCI and therefore was no information to consider prior to the inspection. One immediate requirement was made at the time of the visit to the home. What the service does well: Comprehensive pre admission assessments are compiled to ensure that the home can meet the individual assessed needs of the prospective resident. The home has a comprehensive system for monitoring health needs and emphasis is placed upon maintaining residents independence and socialising skills. Care plans and risk assessments are comprehensive, reviewed regularly and the involvement of external professionals is actively sought. Various activities are available both inside and outside of the home and staff support residents to pursue their interests. There is a pleasant atmosphere in the home and the home is clean and homely in style. Resident’s bedrooms are well decorated and residents are encouraged to have personal items. The home has a core group of staff that have worked at the home for some time. Residents got on well with the staff and positive relationships were noted between the staff and residents. Comments from residents included: “You wouldn’t find a better home than this” “I’ve just had the best dinner” “You can have what you want to eat” “If you want a drink in the night they will bring you one or get you some food” “If you press the button, they come within seconds” “They will do anything for you here” Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have information needed to make an informed choice about whether they would like to live at the home. Comprehensive assessments are carried out prior to a placement being offered so that the home and residents know that the home is able to meet individuals needs. EVIDENCE: The statement of purpose is comprehensive and assists residents to make an informed choice about whether they would like to live at the home. The home has now set up a website and this information is included on the web page. The registered manager confirmed that the service user guide had been reviewed since the last visit to the home and had been issued to all the residents to ensure they had information about living at the home. One resident said “You wouldn’t find a better home than this”, and another said, “I have lived here for 12 years”. The home has a comprehensive pre-admission assessment tool, which has been expanded to include mental health needs, care needs/self care deficits and known risks. The registered manager or the nurse manager carries out assessments; reports are also acquired from external professionals when a placement is being considered and where possible, information from relatives Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 10 is also gathered. This ensures that the home collates, as much information is possible in order to ensure that the home can meet the assessed needs of the residents. Residents have the opportunity to visit the home prior to admission and this ensures that they have the option to experience the home to see if they would like to live there. The managers also have the opportunity to assess their individual needs to ensure that the home can meet them, prior to a place being offered. This reduces the possibility of an inappropriate placement and undue distress to residents if the home were unable to meet their needs. Copies of previous inspection reports are available from the office however it was recommended that a notice is displayed to inform residents and their representatives that the reports are available, so that they have information about the home if required. Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are comprehensive so that staff know how to support the residents to meet their needs. Residents are consulted and assisted to make decisions about their day-to-day lives. Residents are supported to maintain their preferred activities within a risk assessment framework. EVIDENCE: Each resident had a written care plan. This is an individualised plan about what the person is able to do independently and states what assistance is required from staff in order for the residents to maintain their independence. Four care plans were reviewed and the contents included medical, psychiatric and social details, which is valuable when identifying needs. Care plans were detailed and included sexuality, psychological and physical conditions and identified the level of support required. Risks had been identified, assessed and regularly reviewed. The involvement of service users with monthly reviews was well documented. Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 12 Moving and handling assessments were undertaken to ensure that staff had information to meet the needs of the residents safely. Risk assessments were written for residents who required support with smoking and for inappropriate behaviours. Care plans were written for verbal and physical aggression and triggers for these behaviours were identified, one resident who had a mood disorder had early warning signs recorded and this provides information for staff so that they could minimise the potential for this behaviour as they might know what could cause it. There were also instructions for staff what to do when these signs were noted such as “ ask her to use her relaxation techniques and tapes”. Residents meetings are held and the nurse manager stated that one had been held about a month ago, however there were no minutes available. It is required that there is evidence of discussions that have taken place with residents to demonstrate how the views of the residents are acted upon and how improvements are made. Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements in place ensure that people living in the home experience a meaningful lifestyle where their rights are respected. Residents receive a wholesome and varied diet that meets any specific dietary or cultural needs. EVIDENCE: There are no rigid routines in the home and residents were observed to go out of the home as they chose. A record is maintained when some residents leave the home, of clothing worn and some are given a printed note with the home details and contact number and this enables residents to be independent, whilst the home strives to maintain their safety. One resident had been out shopping and on return was welcomed with a hug from the nurse manager and it was evident that this was normal practice. Another resident kept coming into see the managers at various points throughout the day, the resident was upset as was not feeling very well and the manager hugged her also and gave her reassurance. One resident went out to lunch with her friend and other Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 14 residents were seen accessing all communal areas of the home, some residents had chosen to go back to their own rooms. The managers of the home bring in their dog three times a week and the residents of the home were very pleased to see him. One resident picked up the dog and was talking to him and stated, “He’s lovely”. One resident’s room had a fish tank and another resident had previously had a hamster. Residents are supported to look after these animals by the staff at the home. Residents go out to day centres as they choose, one resident commented:” I go out to the day centre but I didn’t want to go today”, and this shows that residents have the choice about how they spend their day. Records reviewed showed that one resident had been out with family and attended the theatre, other residents had been involved in playing dominoes with other residents and staff and there was evidence of residents receiving visitors. Other activities at the home include, yoga, massage, aromatherapy, reflexology, arts and crafts, quizzes, exercises, relaxation and games. A gardening club is held locally which some residents choose to attend and the hairdresser visits on a fortnightly basis. Once a month a church service is held and a nun comes into the home every Friday to assist Roman Catholics to meet their religious needs. A resident who is of Hindu religion goes home with his family so that they can say their prayers together. One resident has magazines delivered to the home and a newspaper is delivered to the home each day. Individual newspapers could be delivered if required to ensure that residents continue to read items that are of interest to them individually. A carer is currently undertaking the role of the activities coordinator and was seen to be assisting residents to do their hair. The home has an open visiting policy and this ensures that residents can see their visitors as they choose. One resident was called into the office by the manager to take a telephone call from his mother. A payphone is also available for residents to use as they choose and is situated in a quiet area of the home to provide privacy. Meals are served in two sittings, the first sitting is for residents who require assistance or may wander away from the table and this allows the staff to spend the time with the residents as required. The second sitting is for residents who are more able and independent. The lunchtime meal was observed and staff were appropriately assisting residents. Various choices of meal were served; portions were of a good size and were nicely presented. Staff waited until all residents had finished and left the room before they tidied and cleaned in preparation for the second sitting and this shows respect for the residents living at the home. Residents are encouraged to take used crockery Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 15 to the serving hatch to promote their social skills. Choices of hot meals are available at lunch and teatime, cooked breakfasts are available and snacks such as yoghurts and fruit are available throughout the day. Comments from residents included: “I’ve just had the best dinner” “You can have what you want to eat” “There was not enough chicken on the bone” Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The privacy and dignity of residents was being upheld and protected by staff. There was a comprehensive and proactive approach towards ensuring that health needs were being met. The management of medication was poor and did not ensure that medication was safely administered. EVIDENCE: Each resident had a written care plan. This is an individualised plan about what the person is able to independently and states what assistance is required from staff in order for the residents to maintain their independence. Resident’s records reviewed showed that where individuals had health needs, staff had observed changes and acted upon these appropriately. Action had been taken to refer the resident to other health professionals to ensure that they received the appropriate treatment. It was clear from records seen that staff support residents and accompany them for appointments outside of the home. Residents were well dressed in styles, which were appropriate for their age group, cultural background and personal preferences. Hairstyles were also Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 17 individualised. One resident ordered her own toiletries from the Avon catalogue, and liked to go shopping for her own clothes and this encourages independence. Residents can choose the time they go to bed or get up and one resident said “I went to bed early last night but I still got up at 7am” There was evidence that residents have access to healthcare professionals such as General Practitioners, Dentists, Opticians, Chiropodists, Social Workers, Psychiatrists and Community Psychiatric Nurses. Records showed that Waterlow scores (a tool which helps to determine the possibility of skin sores) and nutritional scores were reviewed every three months. All residents have monthly blood pressure and a weight check. Residents have a yearly heart check and residents who require antipsychotic medication have regular screening and cholesterol levels are checked. This intervention may ensure that any indications of potential problems with medication are identified early and any necessary changes can be made. The management of medication was reviewed and was found to be poor with a number of discrepancies. Medication is kept in individual boxes and identity photographs are on the Medication Administration Record (MAR) to minimise the risk of drugs being given to the wrong person. The inspectors completed a number of audits and these found that some medications were unaccounted for and others had extra tablets left over. MAR charts had not always being signed when the drug had been administered and one tablet had been given for 15 days without the MAR being signed. Some handwritten MAR charts were in place (usually following a change of medication by the consultant or hospital) and these had not been signed by the person writing the chart. Two staff should sign these charts to ensure that the correct drug and dosage is recorded and confirmed. Ointments and creams were not signed for on the MAR chart so there was no evidence that these had been applied. The amount of stock was unclear, for example one resident had 7 lorazepam tablets signed for yet had three unopened containers and a total of 84 tablets in stock. This meant that audits could not be completed and suggested that other resident’s medication that was the same was being used for all residents, which is not acceptable. Residents who self-administered their medication had no risk assessments written. It was not clear how much medication was received or returned by the home and no staff audits were completed to ensure staff competence for administering medication. Controlled drugs were correct and appropriately stored. Some residents are on a high number of medications, which are complex, and therefore an immediate requirement was left with the Registered Manager to audit all residents’ medications and rectify any discrepancies. The Registered Manager forwarded a comprehensive report to CSCI, following the audit. A number of discrepancies were found and an action plan with timescales for completion has been submitted. The manager stated “the audit process has revealed areas of practice which require change. These changes Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 18 will be implemented”. The management of medication will be further reviewed at the next inspection of the home. Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is comprehensive and accessible to residents and their representatives should they need to make a complaint. The home has appropriate policies and procedures in place that should ensure that residents are protected form abuse, neglect and self-harm. EVIDENCE: A complaints procedure is in place and available for residents and their representatives to use if they need to make a complaint. The home had not received any complaints since the last inspection at the home. CSCI had received one complaint regarding the assessment and non-acceptance of a resident for placement at the home and this was referred back to the provider to investigate using the homes complaint procedure, a copy of the outcome was sent to CSCI and the outcome appropriately recorded. The home had documentation in place to record any complaints and this included a form for recording the complaint, any investigations undertaken and the outcome. Historically the home has had very few complaints, which suggests satisfaction with the service provided. One resident commented “They will do anything for you here”. The home has an appropriate adult protection policy in place, which provides staff with guidelines to follow in the event of an allegation of abuse. All staff has received training in adult protection and this ensures that staff have the Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 20 knowledge to deal with any situations that may occur. There have been no adult protection concerns raised since the last inspection of the home. The home has a whistle blowing policy in place, which ensures staff have the knowledge to protect residents at the home without fear of reprisals. Residents care records reviewed included guidelines on managing the behaviour of individuals. These included triggers for the behaviour, the desired outcome and actions for staff when this behaviour was being displayed. Another record gave details of early warning signs for a resident who had a mood disorder, and some specific details were documented such as “becomes very emotional and cries more than usual”. This information ensures that staff are alerted to any changes in residents behaviour and have guidelines in how to deal with the changes appropriately in order to reduce any potential selfharm. Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment provides a homely, clean and comfortable environment for residents to live where they appear to feel safe and secure. EVIDENCE: On the day of the visit to the home, the home was found to be clean and fresh with no offensive odours. There are two lounges and a dining room all of which were of a comfortable temperature and are bright and pleasant. A smoking room and a separate hairdressing room are also available for residents who choose to use these facilities. A passenger lift is available to the first floor of the home and there is a ramp to the garden area, which would enable residents, or visitors to the home to access the premises easily. Corridors are wide and have handrails, which would enable residents to mobilise independently, if they required assistance. Although not routinely required, a hoist and a stand aid are available and pressure-relieving Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 22 equipment is available for residents who may require this equipment to prevent skin sores. The home has two baths and three showers which meet the needs of the residents living in the home. These include assisted bathing facilities and a walk in shower. One bathroom had wicker furniture, was pleasantly decorated and was very homely and welcoming. One of the shower chairs was noted to be rusty and it was recommended that this is painted to prevent any cross infection occurring. Sluice room doors had coded locks and COSHH (Control Of Substances Hazardous to Health) items were locked away to minimise the risk of residents coming to any harm from these products accidentally. Bedrooms viewed were very personalised with items, which reflected the cultural background, personal tastes and interests of the residents. All bedroom doors have suited locks and a lockable facility is provided inside wardrobes, which enables residents to maintain their privacy as they choose. A number of improvements had been made to the environment since the last visit to the home and these included an upgrade to the bath and shower room, a reduction in one double room to a single room, new flooring in a number of residents bedrooms, new beds and decoration of rooms. This shows that the managers and providers of the home continue to improve the environment to ensure a homely and clean environment is promoted for residents to live in. Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by an appropriate number of staff to ensure that their identified needs are met. There is a robust system for the recruitment of staff so that residents are safeguarded. Staff receive training to ensure that they have the knowledge and skills to meet the individual and collective needs of the residents. EVIDENCE: The home currently has 47 of staff who hold an NVQ level 2 or 3 and the home must continue to work towards increasing this number in order to ensure that a skilled and knowledgeable workforce can provide individual and collective care. The home has a constant supply of student nurses from a local university and these are in addition to the homes staffing levels. The home maintains a stable group of staff and there were no staff vacancies at the time of the visit. In addition to nursing and care staff, the home also employs laundry and kitchen staff and a handyman, and this ensures that all the needs of the residents are met. The Registered Manager and nurse manger are on the premises Monday to Friday in addition to the nursing staff. Two qualified nurses are on duty, throughout the day with five care staff and during Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 24 the nighttime, one trained nurse and three carers are on duty are to support residents. The atmosphere in the home was relaxed and calm and staff were observed to interact with residents and assist them to meet their individual needs. Comments from residents included: “If you want a drink in the night they will bring you one or get you some food” “If you press the button, they come within seconds” No new staff had been appointed to the home since the last inspection. Three longstanding staff files were reviewed and were found to include all the required recruitment information. All files had two written references and a POVA first (Protection of Vulnerable Adults) and CRB check (Criminal Records Bureau). Personal Identification Numbers for trained nurses are checked with the Nursing and Midwifery Council and this ensures that the nurse is currently registered and fit to practice. The Registered Manager informed the inspector that repeat CRB checks were in process for staff who had been employed at the home for three years and this is seen as good practice. The home had the ‘Skills for Care’ induction documentation, however it could not be fully assessed, as there have been no new recruits to the home recently. Each month the nurse manager holds a ‘staff workshop’ where an aspect of training is discussed, the nurse manager is also the designated infection control nurse trainer and provides training to all staff. One of the nurses at the home is a qualified moving and handling trainer and provides training for inductions (including students) and annual updates for all staff. The Registered Manager provides training in fire and health and safety. The managers hold regular meetings to discuss training needs and are clearly committed to ensuring that staff receive training to ensure they have the appropriate knowledge and skills to support the residents to meet their needs. Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst the home has some mechanisms for feedback from residents, a quality assurance system must be fully developed in order to ensure that residents are confident that their views underpin all self-monitoring, review and development by the home. The home routinely undertakes health and safety checks, which ensures that residents are living in a safe environment. EVIDENCE: The Registered Manager is a Registered General Nurse and a Registered Mental Nurse who has a number of years of experience at management level. He has also completed the Registered Managers Award and is able to train staff regarding fire procedures as has completed the West Midlands Fire Service course. The nurse manager is also a Registered General Nurse and a Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 26 Registered Mental Nurse and this ensures a range of knowledge is available to meet the needs of both the residents and staff. A full quality assurance system was not in place and the Registered Manager acknowledged that further work is required. The manager regularly carries out infection control and health and safety audits. Questionnaires were sent out to residents in October last year and the information gathered from these was shared in a resident meeting. Questionnaires were not sent out to relatives or external stakeholders and this is required in order to encompass everyone’s views. A report and an action plan with timescales must be produced to complete the process and this requires attention, as has been an outstanding requirement from the last three inspections. One resident said: “They will do anything for you here”. The providers, or a representative, are required to make an unannounced visit to the home each month and a Regulation 26 report should be written and available for inspection. This is required in order to assist the providers to measure the homes success in meeting its aims and objectives and statement of purpose. One of the nurses at the home is a qualified moving and handling trainer and provides training for inductions (including students) and annual updates for all staff. This ensures that staff have the correct knowledge to assist residents safely. Weekly fire safety checks are completed to ensure that the alarm and equipment is in full working order. A test was completed during the visit to the home. Fire drills are undertaken and a report is written on the success of the drill including any problems and the actions needed to resolve the problems. Staff names are recorded and this enables the manager to ensure that all staff receive at least two fire drills per year in order to update their knowledge so that they would act appropriately and safeguard residents in the event of a fire occurring. Maintenance certificates were available for gas safety; passenger lift, legionella checks and weekly checks are carried out on water temperatures, wheelchairs, emergency lights and other equipment to ensure that it is in full working order and is safe for both the residents and the staff to use. A valid certificate of employers liability insurance was displayed in the home. The Environmental Health Officer had recently been to the home, however the report was not available and it is required that these documents are available for inspection. Wilson Lodge DS0000024909.V331452.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 Adults 18-65 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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 1 X X 2 X Wilson Lodge DS0000024909.V331452.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. 2. Standard YA8 YA20 Regulation 12(2)(3) 13(2) Requirement Evidence of residents meetings and consultations must be available for review. The home manager must complete an audit of all residents’ medications and rectify discrepancies. (The manager received this as an immediate requirement) Regulation 26 visits must be undertaken and a monthly report available for review. The home must complete the development and implementation of an acceptable quality assurance system. (N.B. This remains outstanding from the three previous inspections.) The Environmental Health Office report must be available for inspection. Timescale for action 30/04/07 02/03/07 3. 4. YA39 YA39 26 24 (1) (a,b) (2)(3) 30/04/07 21/05/07 5. YA42 16(2)(j) 31/03/07 Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 29 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. 2. Refer to Standard YA1 YA29 Good Practice Recommendations It is recommended that a notice is displayed to inform residents and representatives that a copy of the inspection report is available. It is recommended that rusty shower chairs are repainted. Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wilson Lodge DS0000024909.V331452.R01.S.doc Version 5.2 Page 31 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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