Inspection on 15/06/06 for Wilton Manor Nursing Centre

This inspection was carried out on 15th June 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

Wilton Manor Nursing Centre 12/07/07

Wilton Manor Nursing Centre 03/02/06

Wilton Manor Nursing Centre 23/02/05

Wilton Manor Nursing Centre 20/07/04

Wilton Manor Nursing Centre 17/02/04

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Ascot Nursing Home

Fountain View

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

CARE HOMES FOR OLDER PEOPLE Wilton Manor Nursing Centre Wilton Avenue Southampton Hampshire SO15 2HA Lead Inspector Mark Sims Unannounced Inspection 15th June 2006 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 Manor Nursing Centre DS0000011455.V289782.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 Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wilton Manor Nursing Centre Address Wilton Avenue Southampton Hampshire SO15 2HA 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) 02380 230555 02380 632076 boodhood@bupa.com ANS Homes Limited Mr Dookhun Boodhoo Care Home 69 Category(ies) of Dementia (13), Dementia - over 65 years of age registration, with number (69), Mental disorder, excluding learning of places disability or dementia (13), Mental Disorder, excluding learning disability or dementia - over 65 years of age (69) Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The number of persons for whom accommodation and nursing care is provided at any one time shall not exceed 69. A total of 13 service users may be accommodated at any one time in the categories of DE and MD between the ages of 50 - 64 years. The home is not registered to take patients detained under the Mental Health Act 1983 - as amended. 3rd February 2006 Date of last inspection Brief Description of the Service: Wilton Manor is a care home providing care for 69 older persons in need of nursing care. The home is registered to provide care for older people with mental diseases associated with old age and those with a mental disorder, excluding learning disabilities. The home has a condition of registration that they may admit up to 13 service users with dementia and those with mental disorder, excluding learning disabilities, between the ages of 50 and 64 years. Wilton Manor is part of a large organisation, which has recently been purchased by BUPA Care Homes and as a consequence the home is experiencing transitional changes associated with the policies and systems of the home. The home is located in the city centre of Southampton and is close to all the local amenities. The home was purpose built on three floors, and provides a modern environment with single occupancy accommodation, all of which have en-suite facilities. Well-maintained gardens surround the building. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first ‘Key Inspection’ for Wilton Manor Nursing Centre, a ‘Key Inspection’ being part of the new inspection programme, which measures the service against the core and/or key national minimum standards. The fieldwork visit, the actual visit to the site of the home, was conducted over two days, where in addition to any paperwork that required reviewing the inspectors met with service users, relatives and staff and undertook a tour of the premises to gauge its fitness for purpose. The inspection process also involved far more pre fieldwork visit activity, with the inspector gathering information from a variety of professional sources, the Commission’s database, pre-inspection information provided by the service and linking with previous inspectors to have visited the home. The new process is intended to reflect the service delivered at Wilton Manor Nursing Centre over a period of time as apposed to a snapshot in time. What the service does well: The inspectors spent two days at the home and throughout that time were treated with consideration, politeness and respect. The staff were very open, friendly and co-operative and the support provided by the senior staff team was exceptional, especially given some of the issues that arose during the visit. Nine comment cards returned prior to the fieldwork visits also indicate that staff are welcoming and comments from two care managers also support the view that staff are supportive and co-operative. Since the home has come under the ownership of BUPA Health Care, the staff report that training opportunities and the diversity of available training has improved, a statement supported by the previous inspector, who reported during her 3rd February 2006 inspection report: ‘The senior nurse discussed the staff-training programme with the inspector, she reported that BUPA have allocated a large training budget to the home to enable her to secure appropriate training for staff’. In discussion with the deputy manager (who oversees training and development), it was established that training programmes are created to meet staff demand and that educational events are generated for both qualified and care staff alike. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 6 The home and/or the staff also manage the pre-admission and admission processes well, with the inspectors observing a room being prepared to receive a new client, with fresh flowers and a welcome card placed into the room ready for the person’s arrival. The relatives of the new client discussing how helpful and supportive the staff were throughout the pre-admission build up, including providing tours of the home, sitting down and talking to people about the service and facilities offered at Wilton Manor, providing clear and informative documents and arranging the room so nicely prior to their relative’s arrival. A care manager also discussed her positive experiences of the home’s admission process and described how the home and/or staff had taken time to sit down with a service user’s family and explore and agree the person’s care plan, prior to admission, given the complex needs associated to that person’s condition. Evidence of completed pre-admission assessments were seen on the service users’ plans and these clearly had links to the care plans, both documents based on the ‘Activities of Daily Living’. What has improved since the last inspection? At the last inspection, undertaken on the 3rd February 2006 the inspector required: ‘You are required to ensure that service users’ monies are paid into individual accounts in the name of that service user. However, on reviewing the system employed by the home to manage people’s monies the inspectors could find no cause for concern, as the system involves: • • • • • • Service users or their relatives/representatives depositing small amounts of cash into a non-interest bearing account. Each service user has both a manual and computerised statement maintained by the home, which records monies deposited, purchases made and transactions undertaken on their behalf. A running total for the cash deposited and balance of the account can easily be audited, given the records and receipts maintained. Accounts that are closed have all monies returned to the client’s estate, all returned monies, etc., are accompanied by letter. Regular statements of the individual client’s contribution are produced and provided to relatives and/or representatives. The principle purpose of this account is to provide a safe and secure resource for service users, where personal allowances and not savings can be deposited for spending on essential items. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 7 What they could do better: During the fieldwork visit the inspectors identified a number of issues which require attention: • The care planning documentation was generally fine, although one or two review dates were noted to have lapsed, although these were addressed during the first fieldwork visit day and therefore will not be mentioned within the main body of the report. One aspect of the home’s documentation, however, that did cause concern for the inspectors was the lack or inadequacy of the home’s (individualised) risk assessments. Risk assessments are generally tools used when identifying potential risks or hazards (for clients) and are the vehicle through which instructions on how to minimise the possible harm are transmitted to staff. Risk assessment tools are therefore required to identify potential hazards and/or risks, rate the potential hazard (likelihood to occur), create a plan to manage the risk level accordingly and regularly review and/or evaluate the risk assessment. • Gaps within the Medication Administration Records (MAR) were noted on occasions and it is imperative that these records be accurately maintained at all times. Whilst an area or room has been set aside for the purposes of activities, it was noted during the fieldwork visit to have been reserved for staff training and therefore not accessible to clients. In conversation with staff it was established that this is a common occurrence and that the room is not considered or used purely for the entertainment of clients, although potentially there is a need for such an arrangement given the sixty nine places available at Wilton Manor. A lack or perceived lack of activities was also the theme of relative’s comment cards returned prior to the fieldwork visit and considering these comments alongside those of staff and the inspector’s observations, the need to establish a permanent and environmentally suitable activities lounge exists. • Alongside the need to create a more permanent activities lounge, comes the need to facilitate access to safe and secure grounds. Currently service users cannot access any external areas of the home unsupervised, as the grounds are not secure. DS0000011455.V289782.R01.S.doc Version 5.2 Page 8 • Wilton Manor Nursing Centre It is the opinion of the inspectors that ground towards the front of the property could be utilised for this purpose and that doors leading from the activities lounge could be created, encouraging people involved in activities, etc. to wander outside (within a safe and secure environment). Again comments from relatives, regarding the lack of opportunity for their next of kin to get out and about, and observations of both inspectors underpin the requirement for BUPA to consider how they might successfully manage this issue. • Both of the fieldwork visit days were undertaken when the weather was relatively hot and sunny, which meant the air temperature, etc., was elevated. During the tour of the premises both inspectors noticed how the temperature within the building increased the higher you went within the property and that due to doors being closed to lounges and dining rooms, etc. these areas were hot, uncomfortable and potentially detrimental to clients’ wellbeing. The inspectors noted during their time in the home that all main corridor doors are fitted with electro-magnetic devices and consideration should be given to extending these to include doors to lounges and dining rooms, etc. BUPA should also establish if any other actions (on their part) could be taken to further manage the excessive heat build up within the home, especially within those areas used by service users and/or their visitors. • The supervision programme for staff has not yet been fully implemented, as identified during conversations with the deputy manager and from records of visits made by company (BUPA) representatives, where the issue was identified as requiring attention. 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. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 9 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 Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 10 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): St 3 & 6. Quality in this outcome area is good. This Judgement has been made using the available evidence, including a visit to this service. The admission process is well managed and ensures that a prospective client’s needs are appropriately assessed and documented prior to admission. The home does not provide an intermediate care service. EVIDENCE: On the day of the first fieldwork visit the inspectors undertook a guided tour of the premises, as neither inspector had visited the service before. During the tour of the property the inspectors observed a member of the administration team placing fresh flowers and a welcome card into a bedroom, which when enquires were made, were for a new resident who was due to arrive shortly. It was established that this is normal practice for the home and is intended to help the person feel welcome and at home. On the second day of the fieldwork visit the relatives of the newly admitted resident mentioned the flowers and the card that had been placed in their next of kin’s bedroom and felt that this Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 11 epitomised the home’s entire ethos of making people feel welcome and relaxed. In discussion with these relatives it was also established that prior to agreeing to the admission of their next of kin they had visited the home and had been impressed by the time taken by staff to talk them through the admission process, facilities and services provided and to tour them round the home. They also discussed how their relative had been visited and assessed prior to admission and the usefulness of the company’s literature and Commission’s reports. Other relatives, via comment cards collected prior to the fieldwork visit, also remarked about being made welcome by the home’s staff and two service user’s questionnaires returned indicate that people were happy with the levels of information, etc. provided to them prior to moving into Wilton Manor. Comments from two care managers provides further evidence of the home’s good practice when it comes to managing the admissions of service users, with both care managers stating they were happy with the overall care provided to their clients and one care manager recounting: ‘How supportive the staff had been when admitting one of her clients to the home, meeting with the family and agreeing care plans prior to the move, in order to manage their anxieties, etc., as the service user had particularly complex needs’. The records or service user plans viewed during the fieldwork visits also contained evidence of the work undertaken with clients prior to admission, each file containing a completed pre-admission assessment, which links into the care planning process and considers the person’s needs against the activities of daily living (a nursing based model of health care). Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 12 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): St 7, 8, 9 & 10. Quality in this outcome area is adequate. This Judgement has been made using the available evidence, including a visit to this service. Care plans address issues affecting clients’ health and social care needs, although risks to their personal safety are less well managed. The health care needs of clients are well managed and access to health and medical support forthcoming. The staff have not been accurately maintaining Medication Administration Records for service users. Issues of privacy, dignity and respect are promoted within the home. EVIDENCE: Twelve care plans or service users’ guides, four from each unit, were reviewed as part of the Commission’s case tracking process, the method used by inspectors to trace or audit the care received by clients since admission. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 13 Generally all of the files inspected were in good order and contained standardised documentation/information: • • • • • • • • • • • • • • • • Photograph of the resident Family/social history Admission details/client information Service user/relative care plan review consent forms Inventory Care planning assessments Care plans based on 12 ‘Activities of Daily Living.’ Falls risk assessments Moving and Handling assessments Waterlow score Bedrail assessments Pre-admission assessments Enquiry forms and information Discharge summaries Medical contacts/notes of visits Wound plans/charts, etc. Two resident’s comment cards returned (by or on behalf of resident), prior to the fieldwork visits, indicate that the care people receive either ‘usually’ or ‘always’ meets their needs. Whilst nine relative’s comment cards returned indicate that if people are unable to make decisions about their own care needs, etc., their families or representatives are ‘consulted about their care’. Two care managers also confirmed that: ‘clients they had placed at Wilton Manor had service users’ plans available and that care appeared to be delivered in accordance with the plans agreed’. One of the care managers also discussed, as mentioned above, how ‘the staff of the home had taken time to agree with one of her client’s relatives his care plan, prior to admission, given the complex needs the gentleman being admitted had’. At the last inspection, 3 February 2006, the inspector recorded that ‘The care plans were detailed in content and risk assessments undertaken for falls, moving and handling and bedrails’. Given the inspector’s experience/observations during the fieldwork visit and based on the comments from previous inspectors, relatives and service users the inspector considers the care planning process to be reasonable. However, whilst the general care planning process is satisfactory the risk assessment documents referred to both at the last inspection and listed above Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 14 were felt to be poorly written and/or constructed, as they failed to adequately reflect: • • • • • The The The The The ‘action’, which might present or lead to a risk. ‘risk’, the potentially harmful outcome of the action. ‘risk rating’, how likely the potentially harmful outcome is to occur. ‘plan’ for managing the potential risk. ‘evaluation’ or periodic review of the risk. Examples of this could be: one plan talks about the person wandering or being restless and agitated, although no risk assessments had been undertaken, despite there obviously being an increased risk of falls due to tiredness or aggression due to increasing agitation, etc. Another client had a risk assessment that referred to triggers, which indicated the potential for physical aggression, although these triggers were not identified on the risk assessment. Several risk assessments discuss people being vulnerable due to falling, despite falling itself not being the risk, injury on landing is more of a risk, which increases depending upon the location the person is in at the time, i.e. cluttered lounges where you might hit something whilst falling, stairwells, etc. The risk assessment documents should consider environmental issues, etc. when considering the potential for people to injure themselves during a fall and what actions they would be required to take in different locations, etc. However, generally the staff approach the promotion of clients’ wellbeing and safety in a positive manner, as evidenced by observations of them using appropriate moving and handling aids whilst assisting residents, ensuring that appropriate hydration was maintained during the hot weather and supporting / liaising with visiting health professionals on behalf of clients. Each of the files inspected was noted to contain a detailed account of all medical visits, whilst in discussion with a visiting physiotherapist it was established that she makes notes directly onto the running records, summarising the visit and future treatment/exercise, etc. The physiotherapist and an associate both described the staff as proactive and responsive to clients’ needs and described how the staff at Wilton Manor were one of the few staff teams to make direct referrals to the physiotherapy service, which greatly speeded up the process. The physiotherapist also felt that all referrals were appropriate and stated that she would prefer staff to refer clients if they felt the services might improve a person’s situation or circumstance. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 15 The physiotherapist also felt the home was well equipped and that staff used the available equipment appropriately and in the best interest of the clients and discussed how staff demonstrated a good understanding of the needs of the people in their care. A local general practitioner who has been visiting the home for almost five years painted a similar picture, describing the service as one of the best local facilities. In discussion he confirmed that he and the staff work in partnership and that any treatment plans prescribed, etc. are followed accordingly, he also felt that the staff demonstrated a clear understanding of the care needs of the clients and that he was satisfied with the overall level of care provided. He also added that he hoped the home’s purchase by BUPA would not change the service’s ability to respond to people’s changing needs, etc., the fear being that increased bureaucracy/administration, etc. might impede the staff’s ability to react quickly to changes in people’s circumstances/health. The general practitioner also stated that he believed that staff managed service users’ medications appropriately, although on inspecting the records maintained by the staff it was noticed that each unit had gaps within its ‘Medication Administration Records’. However, all medications were being appropriately stored and records maintained to evidence when the medicine was received into the home and when they were either disposed of, returned to the client or the course completed. The inspectors also saw evidence of the home’s medication policies, including a homely remedies protocol, which enables people to receive general stock medications, paracetamol, etc. for a limited number of doses without recourse to the general practitioner. Whilst it was not ascertained at this visit whether anyone was self-medicating, it has been reported, via previous inspection reports, that service users have been able to self-medicate and that prior to this process beginning risk assessments were appropriately and properly completed. During the last inspection the inspector reported that the local general practitioner visits two to three times a week to see patients, which remains the current arrangement. In conversation with staff it was established that most clients register with the one health centre, although they are welcome to keep their own doctor (on admission) if they will visit, geographical boundaries often proving a problem. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 16 Whilst conversation with service users was difficult and often non-productive, due to their complex health needs, a comment card completed by a relative, on behalf of her next of kin, indicates that ‘usually’ medical support is available when needed, although no further detail was provided. Another comment card, again completed by a relative on behalf of their next of kin records ‘Don’t know. We understand that there is a Dr to advise on patient medical needs on weekdays’, which indicates their awareness of the arrangements in house for seeking medical advice and support for their next of kin. The comment cards returned also provide evidence of the respect shown to people, as they clearly document how the management and staff welcome people into the home, keep them appraised of issues or events affecting their relative’s wellbeing and involve them in decision-making when their relative is unable to determine for themselves. One comment card specifically comments on the issue of respect and dignity and states: ‘I am completely satisfied with the care my mother is receiving at Wilton Manor. She has advanced Alzheimer’s/dementia and is always treated with respect and in a dignified manner by all staff’. Observations of staff interactions and dealings with residents provided further evidence of the staff’s positive attitudes towards the clients and the respectful way in which they managed their care. One such interaction occurring on the first day of the fieldwork visits when a client was asking to use the telephone to call her sister. The staff obviously had knowledge of the distress these calls sometimes caused the patient and her sister and very carefully and naturally encouraged the client to wait until someone was free to support her with the call. The staff actually took very little time to complete the tasks they had been involved in and then proceeded to place the call for the client, unfortunately the resident’s sister was unavailable, which they established for the resident by giving her the phone to listen to the repeated rings. The client, however, due to her dementia did not recall this and several times returned to the staff to ask if she could call her sister. Each time the staff member was very careful to explain to the client that they had just tried and that her sister was out, however, they promised to try again later and whilst the return call was never witnessed the inspector was confident that the call would be made. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 17 Evidence taken from the previous inspection reports further supports the belief that the home and/or the staff actively promote dignity and respect for the clients of Wilton Manor, the last inspector recording: ‘The inspector observed that staff were treating service users in a kind sensitive manner showing tolerance of the mental incapacity. Service users were observed to be given choice about where they chose to sit and were able to wander around the ward area freely’. Privacy was also an issue commented upon by the professionals involved in visiting the home, with all of the comments received indicating that people are able to visit their clients in private. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 18 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): St 12, 13, 14 & 15. Quality in this outcome area is adequate. This Judgement has been made using the available evidence, including a visit to this service. The lifestyle experience for service users is limited, although steps are taken by staff to address the limiting factors associated to the premises. Visiting arrangements appear satisfactory and meet the needs of both the service users and their relatives. Choice and control over people’s lives is limited by the environment, although were possible choice is promoted. Meals are wholesome, appealing and well balanced. EVIDENCE: Two of the nine relative comment cards returned and one of the comment cards completed by a relative on behalf of their next of kin raise concerns or make observations about the lack of suitable activities for people and the inability of people to get outside unless accompanied. During the fieldwork visit one of the inspectors spoke with representatives/members of the activities team and established that they Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 19 routinely try and get people outside (weather permitting) but due to staffing restriction and the unsuitable grounds it is hard or difficult to entertain more than a few people outside at a time, the grounds of the home being unsecured and providing direct access onto a busy road. The inspectors undertook a tour of the grounds and noted for themselves the problems with gardens, which are unsecured and open to main roads, making them unsuitable for service users to use unaccompanied. The inspectors also noticed however, that an area to the front of the property is currently unused and could with a little work provide a secure area where residents could wander unaccompanied. This would take a little financial commitment from BUPA, as the site would require making secure, level and access from the property created, possibly from the activities room. This would enable people on the ground floor to access an external garden, as and when they desired, as well as promoting for those participating in activities within the lounge the freedom to walk outside if they wished. The inspectors also noted during the tour of the premises that the activities lounge is not used solely for the benefit of clients and was earmarked on the first day of the fieldwork visit for staff training. Given the size of the home and the number of people accommodated it was felt by the inspectors that this facility should be designated as an activities room only, for the sole use of the residents and activities co-ordinators, although some changes to flooring, access, etc. should be considered as part of its reallocation. The activities staff spoken with discussed how they try on a daily basis to provide a range of entertainments, taking into consideration the differing needs and abilities of the people accommodated on each floor and were observed by inspectors involved in sing-a-longs and on the second day of the fieldwork visits gardening with clients, although this was split into three sessions, one for each unit. The senior activities co-ordinator explained during conversation that she has no set budget and that generally she approaches the administration staff for monies to purchase entertainment items, she also added that she has never experienced any problems using this system and was aware there was a limited activities budget and residents’ fund. Whilst again it was difficult to gather feedback directly from the service users on the benefits of the activities arranged, it was evident that those participating in observed events or activities were enjoying themselves. It was Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 20 also noted that where possible families supported or participated in the events (gardening) and they also appeared to enjoying the occasion. Within the main entrance hall and on each of the units the activities team display a schedule of the entertainments they are planning, although as the activities co-ordinators pointed out, these are intended to be guides and are not set in stone, as often people will respond better to one activity than another, depending on how they are feeling that day. It was also established that individualised records, summarising the service users’ participation and enjoyment of an event or activity, have recently been introduced, which should over time provide a valuable account and picture of the service users’ leisure routines. As mentioned throughout the report the inspectors had the opportunity to meet with and/or observe people during visits to residents, providing evidence that the home’s visiting arrangements are appropriate and meeting people’s needs. Eight of the nine comments cards returned from relatives also provided evidence of the suitability of the home’s visiting arrangements with people remarking on the fact that they are able to visit their next of kin and that these visits can be undertaken in private. The home’s brochure (service users’ guide) also makes clear that the service understands and appreciates ‘how important it is to keep in touch with friends and family, so guests are always welcome’, an element of the service the home seems to get right according to both professional and family sources who confirm the welcome to the home is always appropriate. The home also requests that all visitors to the home (and staff) sign in and out on arriving and exiting the premises, which proved a good indicator to the number of visitors to the home and the varying times that people choose to undertake their visits. The general finding of the previous inspection, undertaken on the 3rd February 2006, indicates that service users are being well supported when making independent decisions and exercising their rights to make choices. During the fieldwork visit(s) and as part of the inspection process generally it was established that people are provided with simple choices: • • • • • Rising and retiring times Meal options Where they sit Participation in (internal) activities When they bath, etc. DS0000011455.V289782.R01.S.doc Version 5.2 Page 21 Wilton Manor Nursing Centre It was also evident from observations that staff are prepared to support people with more complex choices, as reported earlier within the report, when an example of the good practice undertaken by staff was recounted, ‘the staff supporting a client in attempting to make contact with her sister’, who was unfortunately not available. However, both inspectors, as reported earlier, felt that the lack of opportunity for people to independently access external areas of the home, plus the limiting or restrictive nature of the premises, i.e. secure/safe units that are set out in a lengthways style, as apposed to circular; and therefore provide no sense of freedom, do represent an obstacle to choice and self-determination. Whilst this is not intended to be a criticism of the staff who work hard to manage the needs of the service users within an often unsuitable environment, it is an issue of concern, which might be eased slightly through the provision of access to a safe and secure garden and increasing the activities available by establishing a permanent activities lounge/room. The issue or concern about the access to external areas of the property, etc. also voiced by relatives via comment cards: ‘It would be nice if there could be some arrangement to take people out to enjoy the fresh air and sunshine’. The feedback regarding meals and menus was a little confusing, as remarks made via the comment cards describe meals as being ‘Usually’ okay and/or ‘meals look plain’. Whilst feedback from service users on the day suggests that meals are considered to be alright, one person stating: ‘the food’s good’ whilst another testified to ‘liking the food’, which would support the observations of the inspector involved in monitoring meals, who described her experience of lunchtime using the following terms: • • • The food smelt good. The food looked appetising The layout of the dining room was appealing. Relatives spoken with during the fieldwork visit also considered the food provided at the home to be good and felt it met the needs of the their next of kin. The inspector also spent time with the catering staff and catering manager discussing a variety of topics: Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 22 • • • • • • • The last Environmental Health Officer’s visit, undertaken on the 17th February 2006, which made no requirements or recommendations. Staff training files, which indicated basic food hygiene had been completed by all staff in May 2006. Dietary needs of the clients, which BUPA address via their own dietary directory for staff. Staff meetings, which for the catering staff occur monthly. Menu choices for clients and maintenance of records. General records maintained by the kitchens Clean schedules, etc. No issues of concern were raised as a consequence of the meetings and discussions with catering staff and the overall picture is of a service that is meeting the dietary needs of its clients. For new or prospective service users a sample menu is included within the home’s brochure (statement of purpose), as is a statement of people’s right to consume meals where they wish, access snacks as and when required and have fluids provided on request. On both days of the fieldwork visits the weather was particularly hot and humid and staff were observed to be regularly offering people drinks to help maintain an appropriate fluid balance. One minor issue noted over the lunchtime period, with regards to fluid and people’s ability to access them, as they wish/desire, was the practice of some staff to pour drinks from the closest or most accessible drinks pitcher, despite one perhaps containing orange and the other lemon, etc. It is important to remember that people should at all times be offered choice and be encouraged to make their own decisions. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 23 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): St 16 & 17 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home appropriately responds to complaints and service users are protected from abuse. EVIDENCE: Seven of the nine relative’s comment cards returned to the Commission state that people are aware of the home’s complaints process and eight of the nine document that they have never had to make or raise a concern. Two comment cards indicate that people are unaware of the home’s complaints process, despite details being included within the home’s terms and conditions of residency documentation. Two service users comment cards, completed on behalf of the service user record that people are either ‘Usually’ or ‘Always’ aware of how to make complaints. Comments from two of the three professionals spoken with indicate that whilst they have dealt with complaints against the service these have always been appropriately received by the home/staff and that their positive response and good record-keeping have helped to manage the issue satisfactorily. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 24 Evidence from the previous inspection report also supports the fact that the home approaches/manages complaints appropriately, the previous inspector recording: ‘The organisation has a complaints policy and details are contained within the statement of purpose. A complaints log is maintained and no complaints had been recorded since the last inspection. It is also reported via the last inspection report that: ’Adult protection training is mandatory for all staff and was identified on the training matrix seen by the inspector and was confirmed when speaking with a number of staff’. During the fieldwork visit it was established with the deputy manager, who oversees the delivery of staff training and development courses, that adult protection training is still considered to be a mandatory course and that she personally delivers the course. The deputy manager was able to demonstrate she was a trained trainer and had completed a course run by ‘Action on Elder Abuse’, although she has built in a large element of the course organised or created by BVS, as there is a video presentation, which accompanies the course, and the audio-visual content is considered beneficial for staff. In discussions with staff it was evident that they are aware of their duty to protect service users from abuse and people recently recruited to the home were able to confirm that as part of their induction training they had completed adult protection awareness training. Records of all training and induction events completed/undertaken by staff are documented. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 25 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): St 19, 25 & 26. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home is well maintained both internally and externally with evidence of ongoing refurbishment and redecoration work noted. The tour of the premises revealed a property that was generally clean and tidy throughout, although the ventilation within lounges, etc., must be reviewed, as these areas of the home were found to be excessively hot. The home was found to be clean and tidy throughout and domestic staff observed on each unit during both days of the fieldwork visits. EVIDENCE: As neither inspector had visited the home before it was decided that the initial tour of the premises should be undertaken in the company of the manager (or appropriate other), enabling the inspectors to familiarise themselves with the layout of the home. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 26 Generally the property was found to be well maintained, both internally and externally and was noted to be clean and tidy throughout. It was also established during the visit that both maintenance and domestic staff teams were available seven days a week and that this level of support allowed the premises to be kept clean and tidy, as well as enabling all minor repairs, etc. to be addressed immediately. In discussion with a member of the domestic staff team it was established that sufficient staff are available to ensure the property remains clean and that whilst the domestic staff undertake general cleaning duties, the maintenance staff operate large equipment like carpet cleaners, etc. On both days of the fieldwork visits staff were noted to have cordoned off areas of the home for carpet cleaning, etc. In discussion with staff it was established that these activities were planned and that agreements with care staff on how to minimise the impact on service users were reached prior to commencing the process. Comments made on behalf of service users indicate that the home is considered to be clean and fresh generally, although an additional comment alludes to concerns over the ventilation of the home: ‘The air can be quite stale but it must be difficult given the high dependency of the patients to prevent this’. This statement could be the result of the heat within the home, as observed by the inspectors and reported upon previously within this report. It is suggested that BUPA review this situation as soon as possible and perhaps consider making arrangements to extend the electro-magnetic door-hold-open devices to include all lounge and dining room doors, this conceivably increasing airflow. Larger maintenance or development issues, it was determined, are addressed via the estates department and are generally either scheduled into the home’s business or improvement plan or earlier if an emergency or priority. Emergency work can also be sanctioned by the home, as BUPA has established a system of preferred contractors, who are responsible for maintaining certain pieces of equipment, lifts, laundry, etc. In conversation with the domestic staff it was determined that this system was recently called upon, as one of the washing machines had broken down and whilst some initial teething problems were encountered the machinery was suitably repaired. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 27 The only other maintenance or environmental issue that is a concern for the inspectors is the lack of access for people to a safe and/or secure garden, which has already been discussed within this report and is a view shared by some relatives. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 28 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): St 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using the available evidence, including a visit to this service. Staffing levels are sufficient to meet the needs of the service users. The home has yet to achieve the target of 50 of the care staff trained to National Vocational Qualification (NVQ) level 2 or above. The recruitment and selection practices of the home are sufficiently robust to ensure that the wellbeing and safety of service users are promoted. In-house training and development opportunities for staff are good. EVIDENCE: Copies of the staffing rosters, supplied during to the fieldwork visits, indicate that the home is well staffed and that sufficient care staff are available, across the twenty-four hour period, to meet the needs of the service users. Observations, on both fieldwork visits days, provided further evidence of the fact that adequate care staff are available to meet people’s care and social needs, this being particularly evident during the second visit when a significant number of the service users were outside enjoying the sunshine with the activities co-ordinators, undertaking some gardening. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 29 It was also evident during mealtimes, when staff were noted to be positioned within all three dining rooms (the home having a dining area per unit), as well as additional carers being available to support people within the lounges and/or their own bedrooms. Service users’ families had mixed views on the availability of the staff, five comment cards out of nine discussing or describing how: ‘In our opinion there are not always sufficient numbers of staff on duty’ whilst the remaining four relative’s comment cards indicate that ‘staffing levels are appropriate’. A view supported by the two comment cards completed on behalf of service users who describe the availability of staff as being ‘Usually’ being alright and/or satisfactory. One additional comment recording: ‘Staff do seem available usually when we would like to ask something’. Professional comments would also appear to support the fact that sufficient and appropriate staff levels are maintained, people’s testimonies indicating that: ‘there is always a senior member of staff to confer with’, although one care manager did discuss how she had been required to investigate a complaint about the home’s staffing levels, which was satisfactorily addressed and felt to be symptomatic of local employment problems at the time. Staff training is a key responsibility of the deputy manager who has taken on the delegated role from the manager, the deputy manager producing and overseeing staff training plans/matrix. During the fieldwork visit the management provided details of the training completed by staff over the last twelve months, which indicated that both mandatory courses and specific training needs are being addressed: Mandatory:Infection Control Food Hygiene Fire safety Manual Handling Adult Protection Specific courses based on needs of service users: Dementia Venepuncture Pressure area care Bereavement, etc New staff interviewed or spoken with during the fieldwork visits confirmed that as part of their recruitment process they received an induction to the service, Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 30 which is based on the relevant ‘Skills for Care’ induction standards and details of the completion of the induction is retained on the staff member’s file. It was also reported during the last inspection that the induction programme introduced by BUPA was in line with the ‘skills induction and foundation programme and can take up to 6 months to complete’, this is more commonly six weeks. Staff are also being supported to access National Vocational Qualifications (NVQ) level 2 courses or equivalent, although the information supplied by the home indicates that the home is still not yet meeting the 50 ratio recommended within the National Minimum Standards. The actual percentage of staff, to date, possessing an NVQ level 2 or equivalent is 42 , although this should shortly rise to 61 when staff complete their course in August 2006. In discussions with the staff it was established that training has become more accessible since BUPA purchased the home, with the deputy manager verifying that training and development appears to be a priority for BUPA, who not only have created a large training portfolio for staff but will also arrange specific courses should enough people ask for the training event. The home’s recruitment and selection process has at previous inspections always been found to be satisfactory and has been considered to: ‘service users are supported and protected by the home’s recruitment policy and practice’. At this visit the files of four newly recruited staff were reviewed and each was found to contain the information required: • • • • • • • • • Completed application forms Details of interview Two references Outcome of Protection Of Vulnerable Adults (POVA) check Outcome of Criminal Records Bureau checks Contracts Induction information. Picture Evidence of ID, etc. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 31 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): St 31, 33, 35, 36 & 38. Quality in this outcome area is adequate. This judgement has been made using the available evidence, including a visit to this service. The manager possesses all relevant care and management qualifications. The home’s quality auditing system adequately takes into consideration the views of the service users. The arrangements for handling service users’ monies are adequate and designed to ensure people’s financial interests are safeguarded. The staff do not receive adequate supervision, although their practice is supervised. The health, safety and welfare of service users and staff is not appropriately managed and promoted. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 32 EVIDENCE: Information contained within the last inspection report records that: ‘the registered manager has been in post for a number of years and is in the process of completing his Registered Manager’s Award’, unfortunately the manager was unable complete the fieldwork visit and the inspectors were unable to discuss his progress with Registered Manager’s Award (RMA). Service users and relatives are afforded the opportunity to discuss concerns with regards to the day-to-day operation of the service at various meetings and via the home’s questionnaires, which are periodically circulated to gather additional feedback from the clientele and/or their relatives. Within the home’s main entrance hall or lobby is a stand containing comment and/or suggestion cards, which can be completed in confidence and deposited within the vessel provided. In addition to the meetings scheduled for relatives, etc. are a series of staff meetings, which cascade information down through the team and are minuted for those not in attendance. The meetings established in house include – management meetings – department meetings – qualified meetings and full staff team meetings. Commission files inspected prior to the fieldwork visit tended to indicate or suggest that since the last inspection BUPA had not undertaken any visits in accordance with Regulation 26 and/or had not produced reports following these visits. However, whilst on the second of the fieldwork visit days the administration manager was able to access copies of the reports produced following the said visits, duplicates of which are available on site. In addition to the visits undertaken in accordance with Regulation 26 of the Care Homes Regulations 2002, BUPA is also undertaking periodic performance review visits, a copy of a performance review action plan, inspected during the visit. This process would appear to be part of a much larger auditing programme that is conducted by the company and used to evaluate internal performance against internal standards, failure to meet the internal standards resulting in an agreed plan of improvement. Another important element of any quality auditing system is the work undertaken with the staff, which from a training and development perspective is good, as evidenced earlier in the report. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 33 However, as evidenced during conversation with the deputy manager and supported by the company’s performance review action plan, the home is currently failing to deliver appropriate formal supervision for staff, although appraisals are occurring annually and are being used to monitor staff performance and development needs, etc. At the last inspection, undertaken on the 3rd February 2006 the inspector required: ‘You are required to ensure that service users’ monies are paid into individual accounts in the name of that service user. However, on reviewing the system employed by the home to manage people’s monies the inspectors could find no cause for concern, as the system involves: • • • • • Service users or their relatives/representatives depositing small amounts of cash into a non-interest bearing account. Each service user has both a manual and computerised statement maintained by the home, which records monies deposited, purchases made and transactions undertaken on their behalf. A running total for the cash deposited and balance of the account can easily be audited, given the records and receipts maintained. Accounts that are closed have all monies returned to the client’s estate, all returned monies, etc., are accompanied by letter. Regular statements of the individual client’s contribution are produced and provided to relatives and/or representatives. The principle purpose of this account is to provide a safe and secure resource for service users, where personal allowances and not savings can be deposited for spending on essential items. In discussion with families/relatives of service users they were more than satisfied with the home’s approach to managing their next of kin’s monies and stated that they felt: ‘this facility offers my mother access to monies if required and me peace of mind’. In addition, all nine of the comment cards returned by relatives and all three professional comment cards returned documented that they are: ‘Satisfied with the overall care provided’, which must be considered to include services such as the financial system established for service users. No immediate health and safety concerns were identified, with regards to the fabric of the premises and full health and safety policies, etc. are made available to staff via BUPA’s internal policies and procedures files. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 34 However, as highlighted earlier within the report the care planning process does lack adequate risk assessments, which should be addressed as soon as possible. The excessive heat and associated health implication are also concerns, as reported within the main body of the report, which will require attention or consideration by BUPA. However, other elements associated with health and safety would appear to be being handled much more effectively with the maintenance team available to immediately address minor repair work and available to undertake fire tests, etc. It was also noted on the second day of the fieldwork visits that an external fire safety consultant had arrived at the home to independently inspect and assess the service, this again being part of BUPA’s commitment to clients’ health and wellbeing. Access to paper towels and liquid soaps was also noted to be possible in all bathrooms and toilets, which is an indicator of the attention paid to infection control, as is the availability of a specific infection control policy. The staff training programme, details of which were seen during the fieldwork visits, provide further evidence of the home’s consideration of health and safety issues with educational programmes such as fire safety, infection control, moving and handling and food hygiene all provided on a regular basis. The home’s brochure (statement of purpose), also commits the home and association to: ‘At BUPA, we believe in the highest standards of care and comfort, provided in a way that is individual to every resident. We aim to achieve this by employing dedicated, well-trained staff and providing comfortable and homely surroundings’. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 35 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 36 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 OP7 Regulation Requirement Timescale for action 10/08/06 2 OP9 3 OP12 4 OP25 Regulation The home must review its risk 13 assessment documents to ensure all risks are identified, rated and plans produced to manage the risk. Regulation The staff must take action to 10/08/06 13 minimise the number of gaps appearing within the medication administration records. Regulation BUPA must consider how it can 10/10/06 12 provide service users with access to safe and secure grounds, for independent use if required. Regulation BUPA must consider how the air 10/10/06 12 within communal areas can be better circulated, reducing the temperature within those areas. If doors are to be held open, as part of this process this must be achieved using appropriate door hold open devises. Regulation The management must ensure 19 staff receive appropriate formal supervision. 5 OP36 10/08/06 Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 37 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 OP28 Good Practice Recommendations The home/management should take steps to ensure that the 50 target of staff possessing and NVQ 2 is achieved and maintained. Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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 Wilton Manor Nursing Centre DS0000011455.V289782.R01.S.doc Version 5.2 Page 39 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!