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Inspection on 16/10/07 for Wilton House Nursing And Residential Home

Also see our care home review for Wilton House Nursing And Residential Home for more information

This inspection was carried out on 16th October 2007.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Some staff provide a good level of care and interact well with the service users. Some care plans have been reviewed and additional information included in the plan ensuring that residents` needs can be met. The activities co-ordinator ensures that residents are consulted on what they would like to do and has spent a lot of time getting to know the residents.

What has improved since the last inspection?

The environment of the home has improved with the replacement of curtains, bedspreads and the repainting of resident`s rooms. Access to the home was secure at this inspection and could only be gained via the keypad. The fire door at the bottom of the stairs leading from the main reception area was now closing properly ensuring people were kept safe.The garden gate has now been made safe and that the area is now safe for residents to access on request. The cleaning trolley was found not to be left unattended and therefore promoting residents safety. Steps have been put in place to ensure that the trolley is not left unattended in the future. The poor lighting in the corridor by the nurses` station has been repaired and provides adequate lighting for the residents and staff. Staff have received additional training in promoting dignity and respect to all residents. The provider has also employed an external agency to conduct an audit and put together a training plan rather than relying so heavily on video training.

What the care home could do better:

The annual quality assurance (AQAA) document that has been completed had little information and the improvements to the service identified were those areas identified by an inspector from the Commission For Social Care Inspection. The document was discussed with the director at the July inspection and the provider was given the opportunity to re-look at the information and send a further copy. An updated copy has not been received. Some further work needs to be carried out with regard to the environment to bring it up to a good standard and provide a homely, welcoming and wellmaintained environment. En-suites require light shades to be put up as the majority were without a shade. Some identified flooring needs to be replaced where it is in a poor state. Staff, especially those who first language is not English, require additional training to ensure they are clear of the safeguarding procedures and understand what is expected if an allegation of abuse is disclosed to them. The manager should consider a training matrix to provide an overview of training completed and this would also identify at a glance any gaps or training needs. Staff records must contain all the relevant information prior to commencing employment. Where information for example letter of recommendation has been transcribed this should be signed and dated to prove validity. Staff must take responsibility when removing rubbish from the home to ensure that the outside bin area is kept clean and free from waste, which will prevent birds and vermin from accessing the discarded waste. Work is still required to ensure that all care plans have been reviewed and they contain all the relevant information pertaining to the residents to ensure that their full care needs are identified and known by staff. The Statement of Purpose still requires updating to reflect what needs the home is able to meet.

CARE HOMES FOR OLDER PEOPLE Wilton House Nursing And Residential Home 73-77 London Road Shenley Hertfordshire WD7 9BW Lead Inspector Mrs Alison Butler Unannounced Inspection 16th October 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wilton House Nursing And Residential Home DS0000019620.V353418.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. Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wilton House Nursing And Residential Home Address 73-77 London Road Shenley Hertfordshire WD7 9BW 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) 01923 858272 01923 856760 Wilton House Limited Linda Fuller Care Home 51 Category(ies) of Dementia - over 65 years of age (51), Old age, registration, with number not falling within any other category (51), of places Physical disability over 65 years of age (31) Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The home may accommodate up to 25 older people who require personal care. The home may accommodate 25 people with physical disabilities who require personal care. The home may accommodate up to 26 older people who require general nursing care or who are elderly mentally infirm and require nursing care. The home may accommodate up to 25 older people with dementia who require personal care. The home must ensure a minimum of 5 suitably qualified and experienced staff work at night within the home. 9th May 2007 Date of last inspection Brief Description of the Service: Wilton House Nursing & Residential Home opened on 3 June 1987. The home is currently registered to admit 51 older people who are physically frail and may have dementia. Following a variation application, the home may now accommodate twenty-six older service users for nursing care within the overall capacity of the home. Wilton House is a purpose built home in a village location. Resident accommodation is single rooms with en-suite facilities. Assisted bathing and toilet facilities are provided. The village shops and pubs are a short distance from the home. Extensive car parking is provided to the rear of the building for visitors. The home is on a sloping site. There is pedestrian access from the main road or residents/visitors can enter the home from the rear car park via the lower ground floor taking the lift to the ground floor. Although there are extensive grounds at the back of the building there is only a very small garden accessible to service users. The Statement of Purpose, Service User Guide and previous CSCI inspection reports are available from the mangers office at Wilton House (a copy of the Service Users Guide will be provided to prospective service users by the home) CSCI inspection reports are also available on the CSCI web site. Up to date information on the fees is available from the manager. Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this unannounced inspection. Time was spent talking with the people who use the service, staff, the manager and a director of the company. Care records and other related records were also examined. The report has been written with information from a random inspection carried out in July, the annual quality assurance (AQQA) document received from the service and with information known to the Commission from accidents and incidents reported through legislation (Regulation 37 notifications). Where information has remained the same, this has been brought forward into this inspection report. Two statutory requirement notices were served at the inspection in July, as the fire door at the bottom of the stairs leading from the main entrance was not closing properly, and the cleaning trolley was left unattended leaving residents at risk. This inspection found that these notices have been complied with. What the service does well: What has improved since the last inspection? The environment of the home has improved with the replacement of curtains, bedspreads and the repainting of resident’s rooms. Access to the home was secure at this inspection and could only be gained via the keypad. The fire door at the bottom of the stairs leading from the main reception area was now closing properly ensuring people were kept safe. Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 6 The garden gate has now been made safe and that the area is now safe for residents to access on request. The cleaning trolley was found not to be left unattended and therefore promoting residents safety. Steps have been put in place to ensure that the trolley is not left unattended in the future. The poor lighting in the corridor by the nurses’ station has been repaired and provides adequate lighting for the residents and staff. Staff have received additional training in promoting dignity and respect to all residents. The provider has also employed an external agency to conduct an audit and put together a training plan rather than relying so heavily on video training. What they could do better: The annual quality assurance (AQAA) document that has been completed had little information and the improvements to the service identified were those areas identified by an inspector from the Commission For Social Care Inspection. The document was discussed with the director at the July inspection and the provider was given the opportunity to re-look at the information and send a further copy. An updated copy has not been received. Some further work needs to be carried out with regard to the environment to bring it up to a good standard and provide a homely, welcoming and wellmaintained environment. En-suites require light shades to be put up as the majority were without a shade. Some identified flooring needs to be replaced where it is in a poor state. Staff, especially those who first language is not English, require additional training to ensure they are clear of the safeguarding procedures and understand what is expected if an allegation of abuse is disclosed to them. The manager should consider a training matrix to provide an overview of training completed and this would also identify at a glance any gaps or training needs. Staff records must contain all the relevant information prior to commencing employment. Where information for example letter of recommendation has been transcribed this should be signed and dated to prove validity. Staff must take responsibility when removing rubbish from the home to ensure that the outside bin area is kept clean and free from waste, which will prevent birds and vermin from accessing the discarded waste. Work is still required to ensure that all care plans have been reviewed and they contain all the relevant information pertaining to the residents to ensure that their full care needs are identified and known by staff. The Statement of Purpose still requires updating to reflect what needs the home is able to meet. Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 7 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. Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 8 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 Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 9 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): 1&3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information available is not up to date and an informed choice would be unable to be made effectively. EVIDENCE: At the inspection in July the Statement of Purpose still required work, as it did not reflect the service offered and referred to other homes within the group. This inspection showed that some work had been done to correct the information but it still does not reflect the full needs that the home can meet. We were informed during the feedback this was in hand at Head Office for all of the homes within the group. A copy will be forwarded to the Commission when it has been updated. A brief assessment had been completed for the newly admitted resident by a member of staff and the resident had received a letter confirming their needs could be met at the home. Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have their needs set out within the care plans, but the records do not always show that their needs have been met. Medication procedures have improved to protect residents. EVIDENCE: At the inspection carried out in July the medication procedures had been tightened up and no medication was seen accessible to service users. At this inspection a discussion took place with the nurse in charge and they felt that the medication delivery has improved and that they now follow up where it has not arrived in the delivery, to ensure that residents have the correct medication when they should. It was observed that a note had been left on the notice board reminding staff to collect an individual’s medication by a set date. The previous inspection in July showed that a high number of residents were seen to be not wearing sock, stockings/tights. The manager had stated it was their choice, however the information was not recorded on their plans at that Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 11 time. At this inspection 1 out of 3 care plans examined had information recorded that it was the choice of the resident to wear or not to wear socks, stockings/tights. Whilst some work had been conducted to the care plans to provide detailed information, further work is still required, this was discussed with the manager and the director at the feedback and they both confirmed that they were working through all the care plans to ensure that they included up to date information and that the information was consistent throughout the plan. A new daily care sheet has been introduced but this was seen to not being completed for all residents on a regular basis. Care plans had been completed for those who were identified at the previous inspection as having mental health needs, although a person who was identified at this inspection had yet to have their care plan updated. Training has been conducted in mental health although not all staff have yet received this and further dates are to be arranged. Wilton House Nursing And Residential Home DS0000019620.V353418.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who use the service have a variety of activities offered to them. Mealtimes are not as pleasurable for the resident as they could be and choice is limited. EVIDENCE: At the inspection in July residents were left unattended at times which put the residents at risk. This inspection showed that this had improved and whilst residents were still left unattended this was only for a very short time whilst they assisted another resident. The garden gate has now been made secure which provides any residents using the garden a safer area to visit. Whilst the residents cannot freely access the garden, as they have to ask for the key, a sign has been put up to let the residents know when it is open and when it is closed. Although on the day the sign stated the garden was open, this was not the case as the manager had to go and get the key to allow the inspectors to access the garden. Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 13 Lunchtime was seen not to be a pleasurable experience as it could be with four staff just standing to one end of the dining room and making no attempt to converse with the residents. Two further staff were sat with residents and talking with them. A discussion took place with the nurse and the manager who agreed that the lunchtime could be made more pleasurable for the residents. More suitable tables were being used in the lounge since the last inspection where they were previously they were too low for the residents to sit comfortably to eat. The activities co-ordinator was not on shift during this inspection. The activities plan stated that cards, jigsaws, and magazines were the activities of the morning and these items were laid out in the activities room. There was little going on in the way of activities and no one was seen during the inspection using the activities lounge. The only exception was that the TV was on in every lounge where the residents were sitting. Staff need to be encouraged to be involved in activities and not be task led. Staff were just sitting next to people in the lounges but were not talking with them and then only dealing with personal needs as and when required. Wilton House Nursing And Residential Home DS0000019620.V353418.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A complaints procedure is in place. Residents may not always be protected from abuse and have their rights upheld. EVIDENCE: Hertfordshire County Council Safeguarding Procedure is available on the wall of the home and training is offered. Some improvement had been made to ensure that staff are clear about the procedure to follow in the event of an allegation of abuse being disclosed to them. However, some staff still had difficulty in answering the inspector’s questions on what they would do if they witnessed or were provided with information regarding an allegation of abuse. The inspectors were unable to gain free access to the home at this inspection and had to use the doorbell. Frequent visitors to the home can safely access the home by the use of the keypad. The July inspection showed that the complaint from the previous inspection had been fully dealt with and the information had been placed in the file. The complaints folder does not contain a log that would show where in the process a complaint is and if there was a satisfactory outcome. The manager and the director stated that they had received a number of compliments regarding the recent redecoration. Wilton House Nursing And Residential Home DS0000019620.V353418.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents live in a recently decorated environment, which makes Wilton House look more homely. Not all infection control measures are in place for the protection of residents and staff. EVIDENCE: On arrival at the home the bin area outside in the car park again contained bins that were overflowing with rubbish and a large number of rubber gloves scattered on the floor around the bin area. At least one of the bins had only a small amount of rubbish in them but was further away from the main entrance to the bin area. This had been addressed by the time the inspectors left the home. Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 16 A tour of the home showed an improvement in the overall decoration and new curtains and bedspreads had been purchased. The manager stated that choice had been offered to the residents regarding the colour scheme for their room, but those that were spoken to they said that “they just came in and put them up”, but all residents and visitors thought they were very nice and brightened the place up. It was noted that some of the fitted furniture had been repaired a number had still not got handles and some shelves were missing. The manager stated that an audit would be undertaken by the maintenance man and repairs or missing fixtures completed where identified. It was noted that where some of the surfaces had been repainted they were not finished to a good standard as some were uneven where the surface underneath had bubbled. The director also said that a full audit is to be carried out to replace carpets and furniture as rooms become available, a copy of the plan will be forwarded to the Commission. The majority of the en-suites were lit with bare light bulbs, as they had no light shades. In one en-suite there was a large gap in the flooring around the pedestal. This does not allow for effective cleaning of the en-suite. It was positive to see that bathrooms were not being used as storage facilities during this inspection. The environment of the bathrooms could be improved to provide more pleasant surroundings for those who use them, as they are very bare with plain walls and no curtains, some of the bathrooms floors were in need of cleaning. The cleaning trolley was not seen unattended during this inspection and the statutory requirement notice served following the last inspection had been met. Staff have received instruction on ensuring that the cleaning trolley is secure at all times to protect the residents. One of the sluice rooms visited during the tour of the home contained a sharps box that was accessible to the residents putting them at risk; the manager stated that this would be addressed immediately. The corridor lighting, which was not working at the previous inspection, had been fixed. Liquid soap dispensers had still not been purchased for the home, and not all bins have lids. The home was generally clean and tidy, but some windowsills in resident’s rooms were in need of a clean as they were dusty and dirty. Wilton House Nursing And Residential Home DS0000019620.V353418.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The personal needs of the people are met by the adequate deployment of staff. Staff recruitment procedures are not robust and may put people at risk. EVIDENCE: The last two inspections showed that not all staff fully understand the principles of safeguarding, although they stated that they had received training. The management state that discussions have taken place during staff meetings on providing dignity and respect at all times to the residents who live at the home. Training was discussed at the inspection in July and the majority of it was noted provided by video, followed by a question paper assessing competence. A discussion with the manger and the director at the end of the inspection informed us that they are now using an external agency to provide more of their training. There is still not a matrix available to provide an overview of the training completed or if there are any gaps. Staff records were examined, on one of the three files examined there was only one references, no terms and conditions, and the transcribed letter of recommendation was not signed and dated to give some proof of validity. Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 18 Observation of staff during lunchtime still showed that whilst some staff offered good care others were seen not to interact with the residents or offer them choice of portions sizes, or drinks. One member of staff when asked by the inspector what the choices were for lunch stated, “They cannot choose”. Wilton House Nursing And Residential Home DS0000019620.V353418.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of Wilton House Ltd have worked hard to implement the requirements made at the previous inspections showing a commitment to improving the service provision for those who live in the home. EVIDENCE: At the inspection in July we were able to gain free access to the home via the front door and were able to get to the first floor without being challenged. On arrival at this inspection the front door was locked and we could only gain access by using the doorbell. Frequent visitors to the home are able to safely access the home by using the security keypad. The requirement made at the previous 2 inspections has now been met and residents are provided with a more secure environment. Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 20 Two statutory requirement notices were served at the inspection in July, as the fire door at the bottom of the stairs leading from the main entrance was not closing properly, and the cleaning trolley was left unattended leaving residents at risk. This inspection found that these notices have been complied with. The fire service have conducted a recent fire safety check and a number of requirements were made, which the manager states have been addressed, they are due to conduct a further inspection in November to check compliance. At this inspection it was noted that the office door was still wedged open and this had been noted on the fire service report that this practice must cease. Computer access is still not available within the service that would benefit the manager and the staff. As most of the information from professional agencies – including CSCI is now cascaded via the Internet the manager stated she has to access the information using her home computer. Access to the Internet would also support the activities co-ordinator who also has to do research at home and this has proved a valuable resource to support her in providing for the needs of the residents. Wilton House Nursing And Residential Home DS0000019620.V353418.R01.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 2 X 2 2 2 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 22 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 OP7 OP8 Regulation 13(4)(b) & (c) Requirement Timescale for action 31/12/07 2. OP7 OP8 OP10 OP15 12(4)(a) 3. OP19 OP21 OP23 23(2)(b)( d)(e)(h) & (p) Risk assessments must be consistent, fully completed and be meaningful to the individual so that staff can provide appropriate care that meets the person’s needs. The requirement is repeated but has been partially met. The timescale has been extended as an audit of care plans continues. 31/12/07 Residents must have their dignity and respect promoted and protected at all times. E.g. the following practices must cease - staff do not engage with residents at mealtimes; choices regarding the use or non-use of socks/tights is not recorded on all files. Where residents have made a choice this must be recorded. The requirement is repeated but has been partially met. The timescale has been extended to allow for the work in progress to be continued and concluded. The decoration of the home must 31/12/07 be brought up to an acceptable standard to provide a safe and DS0000019620.V353418.R01.S.doc Version 5.2 Wilton House Nursing And Residential Home Page 23 OP24 OP25 4. OP30 18(1)(a) 5. OP18 OP28 13(6) 6. OP1 4 7 OP29 OP31 17(10(a) & 19 schedule 2 13(3)&16 (j) 8 OP26 comfortable environment for the residents. The requirement is repeated but has been partially met. The timescale has been extended to allow for the work in progress to be continued and concluded. Care staff must be trained and competent to meet the needs of residents e.g. Mental health training must be provided to all staff. The requirement is repeated but has been partially met. The timescale has been extended to allow time for the training to be provided to all staff. Care staff must be trained and understand how to protect service users from being harmed. Safeguarding training must be provided to ensure service users are kept safe. The requirement is repeated but has been partially met. The timescale has been extended to allow for the work in progress to be completed. The Statement of Purpose must be updated to ensure it contains current and correct information e.g. the correct name of the home. The requirement is repeated. The timescale has been extended to allow for the completion of the work in progress. Staff records must contain all the relevant information as required in the Care Home Regulations, to ensure service users are protected at all times Liquid Soap dispensers must be purchased that meet with the Health & Hygiene requirements to prevent infection. 30/11/07 30/11/07 30/11/07 31/10/07 30/11/07 Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 24 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 OP37 Good Practice Recommendations Progress notes pertaining to the care given should be more explanatory and provide better details for reliable evaluation of the care plan. Some work has been carried out and further training is to be included. The provision of a computer for the manager’s office is recommended to assist various aspects of management. Current information from CSCI and other agencies is now passed electronically. It is recommended that a matrix is placed in the complaints log to give an overview of where in the process a complaint is and any action and outcome is recorded. It is recommended that a training matrix be maintained so that the manager can have an overview of what training has been provided, to who and the date the training was provided. This will assist in ensuring training updates are provided as required and assist in auditing. 2. OP38 3. 4. OP16 OP30 Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Wilton House Nursing And Residential Home DS0000019620.V353418.R01.S.doc Version 5.2 Page 26 - 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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