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Inspection on 30/09/04 for Wingham Court

Also see our care home review for Wingham Court for more information

Care Home For Adults (Mixed Category)Wingham CourtOaken Lane Claygate Surrey KT10 0RQAnnounced Inspection30th September 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Wingham Court Address Wingham Court, Oaken Lane, Claygate, Surrey, KT10 0RQ Email address Name of registered provider(s)/company (if applicable) BUPA Care Homes (AKW) Ltd Name of registered manager (if applicable) Mrs Mary Hagon Type of registration Care Home No. of places registered (if applicable) 73 Tel No: 01372 464612 Fax No: 01372 462421Category(ies) of registration, with (number of places) Old age, not falling within any other category (53), Physical disability (20) Registration number H090000442 Date first registered 10th September 2003 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 3rd March 2004 YES YES 26/04/04 If Yes refer to Part CWingham CourtPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 330th September 2004 10:30 am Sarah RadlettID Code145794Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMrs Mary HagonWingham CourtPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Adults (18 - 65) & Older People 1. Choice of Home Adults (18 - 65) & Section 1.Older People 2. Individual Needs and Choices Adults (18 - 65) & Section2. 7.1 ­ 7.6 Health and Personal Care Older People 3. Lifestyle Adults (18 - 65) & Section 3. Daily Life and Social Activities Older People 4. Personal and Healthcare support Adults (18 - 65) & Section 2. 8.1 ­ 11.12 Older People 5. Concerns, Complaints and Protection Adults (18 - 65) & Section 4. Older People 6. Environment Adults (18 - 65) * Section 5. Older People 7. Staffing Adults (18 - 65) & Section 6. Older People 8. Conduct Management of the Home Adults (18 - 65) & Section 7. Older People Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementWingham CourtPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care inspection (CSCI), is subject to inspection, to establish if the establishment/agency is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Wingham Court. The inspection findings relate to the National Minimum Standards (NMS) for Adults (18 ­ 65) and Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · · · · · · · · Inspection methods used Key findings and evidence Overall ratings in relation to the standards Compliance with the Regulations Required actions on the part of the provider Recommended good practice Summary of the findings Providers response and proposed action plan to address findingsThis report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Wingham CourtPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Wingham Court is a purpose built home providing nursing care for 73 residents. The home is separated in two units Ruxley, providing accommodation for 53 older persons and Claremont, providing accommodation for 20 young adults. The home was initially registered as two separate Care Homes, and registration was combined under the name of Wingham Court in September 2003. The two units are staffed and run independently and have one combined manager, Mrs Mary Hagon. The home is in a rural setting close to the village of Claygate. It has extensive wellmaintained grounds. Accommodation is provided in single rooms, all of which have en-suite facilities.Wingham CourtPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)Wingham CourtPage 6 This was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2004 to March 2005. The home is registered for service users from the Younger Adults and Older Person categories, and was thus assessed against both National Minimum Standards. For details of how each standard was met please refer to the main body of the report. It will be necessary to review both inspection reports for 2004-05 to obtain a full understanding of the extent to which the home meets The National Minimum Standards for Younger Adults & Older People. The staff were observed to be polite and courteous and the atmosphere within the home was relaxed and friendly. The inspector wishes to thank the staff and service users for their cooperation during the inspection. Choice of Home (Standards 1-5 Younger Adults & Standards 1-6 Older Persons) 5 of the 5 standards assessed were met The homes Statement of Purpose and Service Users Guide were seen. Prospective service users or their representatives are encouraged to visit prior to admission. Due to the complex needs of some of the service users it is not always appropriate for the service users to visit the home prior to admission, in this incidence staff are able to visit the prospective service user in their current setting and assist in providing their care. Individual Needs & Choices (Standards 6-10 Younger Adults & Standards 36-37 Older Persons) 5 of the 5 standards assessed were met All service users have a care plan, samples of which were seen and found to clearly demonstrate how the service users needs will be met. Following conversation with staff and service users it is evident that the service users are encouraged to be as independent as possible and to make their own choices, such interactions were observed. All service users have risk assessments, encouraging them to live as independently and as safely as possible. Lifestyle (Standards 11-17 Younger Adults & Standards 12-15 Older Persons) 6 of the 6 standards assessed were met From examination of the activities programmes and talking to staff it is evident that there is a full and varied range of activities available to service users. The home encourages relatives to visit and operates an open visiting policy. Service users are encouraged to bring in their own personal possessions to personalise their rooms, evidence of this was seen during the inspection. Personal & Healthcare Support (Standards 18-21 Younger Adults & Standards 8-11 Older Persons) 4 of the 4 standards assessed were met 24 hour nursing care is provided at Wingham Court, a local General Practitioner visits when required. The service users can also access a variety of health care professional services including dentist, optician and chiropodist. Concerns, Complaints and Protection (Standards 22-23 Younger Adults & Standards 16-18 Older Persons) 2 of the 2 standards assessed were met The home has a complaints procedure, which is available to all service users and clearly displayed within the home. All appropriate policies and procedures are in place. Environment (Standards 24-30 Younger Adults & Standards 21 ­26 Older Persons) Wingham Court Page 7 8 of the 8 standards assessed were met The home is suitable for its stated aims and purpose. The home was purpose built, has appropriate disability adaptations and is thus suitable for its purpose and able to meet the service users needs. The building was found to be clean, hygienic and free from odour. Staffing (Standards 31-36 Younger Adults & Standards 27-30 Older Persons) 6 of the 6 standards assessed were met The two units, Claremont and Ruxley are staffed independently, with the manager overseeing both units. Ruxley maintains staffing numbers of three trained nurses during the day with nine carers in the morning and seven in the afternoon, and two trained nurses and four carers at night. Claremont has one trained nurse at all times and eight carers during the day and four at night. The home has a clear recruitment policy. The required checks are in place for staff employed within the home. There is a comprehensive induction programme in place and staff receive ongoing training which includes service user specific training. Conduct and management of the home (Standards 37-43 Younger Adults & Standards 31-35, 37-38 Older Persons) 7 of the 8 standards assessed were met The registered manager is experienced and competent, with the skills necessary to run Wingham Court efficiently and to ensure that the needs of residents are met. All interactions observed between the manager, staff and service users evidenced an open, positive and inclusive atmosphere. The home has a quality audit system in place; all aspects of the home are audited on an annual basis with some aspects being reviewed on a more regular basis, as need dictates. The manager is aware of the need to maintain a safe environment for service users and staff. Required policies, procedures and safety checks were inspected and seen to be in order to ensure so far as is reasonably practicable, the health, safety and welfare of service users and staff. Service users personal allowances are dealt with by the home. Individual transaction records are maintained on computer. All of the service users monies are currently kept in one account. It is required that all services users monies are kept individually and not pooled.Wingham CourtPage 8 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 Op 28 It is recommended that the home continues working towards the requirement that 50 of all care staff are trained to NVQ level 2 or above by 2005.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Up to 30 beds may be used for rehabilitation of elderly post-stroke patients Up to 16 beds may be used for respite and short stay care Up to 3 beds may be used for palliative careMet (Yes / No) YES YES YESWingham CourtPage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action That all services users monies are kept 1 20 (1)(a) Op 35 30/12/04 individually and not pooled.RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * It is recommended that the home continues working towards the requirement that 50 of all care staff are trained to NVQ level 2 or above by 2005.1Op 28* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. MX10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this reportWingham CourtPage 10 Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Relatives/significant others survey/feedback Service user survey Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)YES YES YES YES YES NO NO NO YES YES YES YES YES YES NO NO NO YES NO YESX X 0 NO NO YES YES X X 30/09/04 10.30 5Wingham CourtPage 11 As this establishment accommodates residents who are both over and under 65 years, the report format reflects the likely differing needs by drawing together the National Minimum Standards for Care Homes for Older People and for Adults (18 ­65). Both sets of Standards are broadly similar, but where there are differences these have been highlighted in italics. The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Wingham CourtPage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they choose will meet their needs and aspirations · Prospective service users have an opportunity to visit and to `test drive the home. This process will also involve the service users relatives and friends. Each service user has an individual written Contract or statement of terms and conditions with the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home.· ·Standard 1 (1.1 ­ 1.4) Y.A & Standard 1 (1.1 ­ 1.3) O.P The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides prospective and current service users with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2 (Y.A), 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10 (O.P): a summary of this information appears in the homes service users guide. Range of fees charged From (£) 830 To (£) 2000Any charges for extras If yes please state what the extras are:YESHAIRDRESSING & PERSONAL ITEMS 3 Key findings/Evidence Standard met? The home has an appropriate Statement of Purpose and Service Users Guide. They contain all the information required by the National Minimum Standards.Wingham CourtPage 13 Standard 2 (2.1 ­ 2.8) Y.A. & Standard 3 (3.1 ­ 3.5) O.P. New service users are admitted only on the basis of a full assessment undertaken by people competent/trained to do so, involving the prospective service user, his/her representatives (if any) and relevant professionals using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? New service users are admitted following a comprehensive assessment by the manager or deputy.Standard 3 (3.1 - 3.10) Y.A. & Standard 4 (4.1 ­ 4.4) O.P. The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Discussion with staff and examination of the care plans demonstrated that the changing needs of the service users are reviewed and recorded. The plans illustrated that the home is able to meet all their needs.Standard 4 (4.1 ­ 4.5) Y.A. & Standard 5 (5.1 ­ 5.3) O.P. The registered manager invites prospective service users to visit the home and to move in on a trial basis, before they and/or their representatives make a decision to move there, and unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? Prospective service users or their representatives are encouraged to visit prior to admission. Due to the complex needs of some of the service users it is not always appropriate for the service users to visit the home prior to admission, in this incidence staff are able to visit the prospective service user in their current setting and assist in providing their care.Standard 5 (5.1 ­ 5.5) Y.A. & Standard 2 (2.1 ­ 2.2) O.P. The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? All service users are provided with a statement of terms and conditions / contract at the point of admission to the home.Wingham CourtPage 14 Standard 6 (6.1 ­ 6.5) O.P. Where service users are admitted only for intermediate care, dedicated accommodation is provided, together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home does not provide intermediate care.Wingham CourtPage 15 Individual Needs and Choices· · · · · Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept.Standard 6 (6.1 ­ 6.10) Y.A. The registered manager develops and agrees with each service user an individual Plan generated from a comprehensive assessment, which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? All service users have a care plan, samples of which were seen and found to clearly demonstrate how the service users needs will be met.Standard 7 (7.1 ­ 7.7) Y.A. & O.P. general good practice Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? Following conversation with staff and service users it is evident that the service users are encouraged to be as independent as possible and to make their own choices, such interactions were observed.Standard 8 (8.1 ­ 8.5) Y.A. specific & O.P general good practice The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard Met? Regular service user meetings take place within the home; relatives are invited to these meetings every six months. Service users are encouraged to participate in the day to day running of the home, the level of their involvement is as dictated by their condition.Wingham CourtPage 16 Standard 9 (9.1 ­ 9.4) Y.A. Specific & O.P general good practice Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? All service users have risk assessments, encouraging them to live as independently and as safely as possible. Samples of risk assessments were seen and found to be satisfactory.Standard 10 (10.1 ­ 10.6) Y.A. & Standards 36 & 37 O.P. Staff respect information given by service users in confidence, and handle information about service users, in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? A selection of records were seen. They were adequately maintained and stored securely. The home has a confidentiality policy and service users can access their records if required.Wingham CourtPage 17 Lifestyle· · · · · · · Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes.Standard 11 (11.1 ­ 11.4) Y.A. specific & O.P. general good practice Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? A wide range of functional activities is provided. The service users in the younger adult unit are encouraged to be involved in goal setting with a view to developing the skills required to live independently.Standard 12 (12.1 ­ 12.6) Y.A. specific & O.P. general good practice Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? From examination of the activities programmes and talking to staff it is evident that there is a full and varied range of activities available to service users. The home employs an activities assistant who ensures that the activities programme is displayed on the notice board and distributed to the service users. Standard 13 (13.1 ­ 13.5) Y.A. & Standard 13 (13.1 ­ 13.6) O.P. Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans and service users preferences. 3 Key findings/Evidence Standard met? Service users regularly access the local facilities and visit local village of Claygate.Wingham CourtPage 18 Standard 14 (14.1 ­ 14.6) Y.A. & Standard 12 (12.1 ­ 14.6) O.P. Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? There is a wide and varied range of activities available to service users. The older persons are able to participate in art, craft, gardening, ball games, board games, quizzes and various trips out. The younger adults benefit from activities such as fishing, basketball, cooking, videos, gardening, cinema, bowling, shopping. In addition to this the younger adult unit has a games room where the service users can play snooker and table tennis. A cyber café is planned for the beginning of next year. Standard 15 (15.1 ­ 15.5) Y.A. & Standard 13 (13.1 ­ 13.6) O.P. Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary) service users are able to have visitors at any reasonable time. 3 Key findings/Evidence Standard met? The home encourages relatives to visit and operates an open visiting policy.Standard 16 (16.1 ­ 16.11) Y.A. & Standard 14 (14.1 ­ 14.5) O.P. The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Service users are encouraged to bring in their own personal possessions to personalise their rooms, evidence of this was seen during the inspection. Staff were observed to be offering appropriate choice to service users.Standard 17 (17.1 ­ 17.9) Y.A. & Standard 15 (15.1 ­ 15.9) O.P. The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Wingham CourtPage 19 Personal and Healthcare support· · · · Service users receive personal support in the way they prefer and require. Service users physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the homes policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Y.A. & Standard 10 (10.1 ­ 10.7) O.P. Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives with particular regard to personal care giving social contact and consultation. 3 Key findings/Evidence Standard met? Staff were observed to respect the service users privacy and to treat them with dignity.Standard 19 (19.1 ­ 19.5) Y.A. & Standard 8 (8.1 ­ 8.13) O.P. The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 313 Key findings/Evidence Standard met? 24 hour nursing care is provided at Wingham Court, a local General Practitioner visits when required. The service users can also access a variety of health care professional services including Dentist, Optician and Chiropodist. One service users was admitted to the home with a pressure sore, the home has appropriate pressure relieving devices available.Wingham CourtPage 20 Standard 20 (20.1 ­ 20.14) Y.A. & Standard 9 (9.1 ­ 9.11) O.P. The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines 3 Key findings/Evidence Standard met? The medication policy, administration records and storage facilities were inspected and found to be in order.Standard 21 (21.1 ­21.8) Y.A. & Standard 11 (11.1 ­ 11.12) O.P. The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? Comprehensive policies and procedures are in place covering death and care of the dying. Staff are aware of the differing religious and spiritual needs of the service users.Wingham CourtPage 21 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · Service users and their relatives and friends feel their views and their complaints are listened to and acted on. Service users are protected from abuse, neglect and self-harm. Service users legal rights are protected.Standard 22 (22.1 ­ 22.7) Y.A. & Standard 16 (16.1 ­ 16.4) O.P. The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and times-scales, for the process, and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 11 0 2 9 0 0 100 3 Key findings/Evidence Standard met? The home has a complaints procedure, which is available to all service users and clearly displayed within the home. The home has received eleven complaints, all of which have been suitably investigated and resolved.Wingham CourtPage 22 Standard 23 (23.1 ­ 23. 6) Y.A. & Standard 18 (18.1 ­ 18.6) O.P. The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. Standard 17 (17.1 ­ 17.3) O.P. specific Y.A. general good practice Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POCA/ POVA lists YES 03 Key findings/Evidence Standard met? All appropriate policies and procedures are in place. Staff spoken to were aware of these policies and procedures and of adult protection issues.Wingham CourtPage 23 EnvironmentThe intended outcomes for the following set of standards are: Service users live in a homely, comfortable and safe environment with indoor and outdoor communal facilities. · Service users bedrooms suit their needs and lifestyles are safe, comfortable with their own possessions around them. · Service users bedrooms promote their independence. · Service users toilets and bathrooms provide sufficient privacy and meet their individual needs. · Shared spaces complement and supplement service users individual rooms. · Service users have the specialist equipment they require to maximise their independence. · The home is clean pleasant and hygienic. Standard 24 (24.1 ­ 24.13) Y.P. & Standard 22 (22.1 ­ 22.8) O.P. The homes premises are suitable for its stated purpose; accessible, safe and wellmaintained; meets service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? The home is suitable for its stated aims and purpose. The majority of the accommodation is well maintained, decorated and furnished to a high standard; however Claremont, younger adult unit, was undergoing redecoration at the time of the inspection. ·Wingham CourtPage 24 Standard 25 (25.1 ­ 25.8) Y.A. & Standard 23 (23.1 ­ 23.10) O.P. The registered person provides each service user with a bedroom which has useable floor space sufficient to meet individual needs and lifestyles which meets minimum space as follows: Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of rooms accommodating wheelchair users with at least 12sq.m of space Total number of rooms accommodating wheelchair users with less than 12sq.m of space Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO NO 73 73 0 0 730X X 0 03 Key findings/Evidence Standard met? All room sizes comply with the National Minimum Standards and this standard was met in full.Wingham CourtPage 25 Standard 26 (26.1 ­ 26.4) Y.A. & Standard 24 (24.1 ­ 24.8) O.P. The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? A tour of the home showed that individual rooms are furnished in a homely way. Service users are encouraged to bring their own possessions with them to personalise their rooms.Standard 27 (27.1 ­ 27.6) Y.A. & Standard 21 (21.1 ­ 21.9) O.P. The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? All bedrooms have en-suite facilities; in addition to this the home has assisted bathing and toilet facilities, which are appropriately situated.Standard 28 (28.1 ­ 28.3) Y.A. & Standard 20 (20.1 ­ 20.7) O.P. A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? The homes communal space is provided by lounge and a lounge / dining room on the ground floor, a large and a small lounge on the first floor and a lounge, a games room and a video room in the younger adults unit.Standard 29 (29.1 ­ 29.8) Y.A. & Standard 22 (22.1 ­ 22.8) O.P. The registered person ensures the provision of the environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? The home was purpose built, has appropriate disability adaptations and is thus suitable for its purpose and able to meet the service users needs.Standard 30 (30.1 ­ 30.9) Y.A. & Standard 26 (26.1 ­ 26.9) O.P. The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The building was found to be clean, hygienic and free from odour. The home has a suitable laundry and handwashing facilities are appropriately situated.Wingham CourtPage 26 Standard 25 (25.1 ­ 25.8) O.P. specific & Y.A. general good practice The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? The heating, lighting, water supply and ventilation were found to be satisfactory. Thermostatic valves are fitted and checked regularly.Wingham CourtPage 27 StaffingThe intended outcomes for the following set of standards are: · · · · · · Service users benefit from clarity of staff roles and responsibilities. Y.A. specific & O.P. advice Service users are supported by competent and qualified staff. Service users are supported by an effective staff team with appropriate numbers and skill mix. Service users are supported and protected by the homes recruitment policy and practices. Service users individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. Y.A. specific & O.P. advice.Standard 31 (31.1 ­ 31.7) Y.A. specific & O.P. general good practice The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? Staff have appropriate job descriptions and staff spoken to were aware of their role and responsibilities. All staff have access to the homes policies and procedures.Standard 32 (32.1 ­ 32.6) Y.A. & Standard 27 (27.1 ­ 27.7) O.P. Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? The two units, Claremont and Ruxley are staffed independently, with the manager overseeing both units. Ruxley maintains staffing numbers of three trained nurses during the day with nine carers in the morning and seven in the afternoon, and two trained nurses and four carers at night. Claremont has one trained nurse at all times and eight carers during the day and four at night. The home has adequate ancillary staff.Wingham CourtPage 28 Standard 28 (28.1 ­ 28.3) O.P. specific A minimum ratio of 50 trained members of staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 9 X 3 Key findings/Evidence Standard met? Nine members of staff have currently completed NVQ level 2. A member of staff is part way through level 3 and another is part way through level 2. It is recommended that the home continues working towards the requirement that 50 of all care staff are trained to NVQ level 2 or above by 2005.Wingham CourtPage 29 Standard 33 (33.1 ­ 33.11) Y.A. specific & O.P. general good practice The home has an effective staff team, with sufficient numbers and complementary skills to support service users assessed needs at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs Total No. of staff hours required No. of staff with NVQ level 2 or above X X X 9 X No. staff hours allocated No. staff hours allocated Total No. of staff hours provided X X X X XNo. of trainees registered on Sector Skills Council training programme No. of staff with nursing qualifications (where applicable) Key findings/Evidence This standard was not assessed at this inspection.X 0Standard met?Standard 34 (34.1 ­ 34. 8) Y.A. & Standard 29 (29.1 ­ 29.6) O.P. The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The home has a clear recruitment policy. The required checks are in place for staff employed within the home. Samples of staff files were seen and found to be in order.Wingham CourtPage 30 Standard 35 (35.1 - 35.8) Y.A. & Standard 30 (30.1 ­ 30.4) O.P. The registered person ensures that there is a staff training and development programme which meets Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? There is a comprehensive induction programme in place and staff receive ongoing training which includes service user specific training.Standard 36 (36.1 ­ 36.8) Y.A specific & O.P. general good practice Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Staff receive formal supervision on a six weekly basis. The manager undertakes supervision of the heads of department who then supervise the rest of the staff team. All staff spoken to feel happy and supported in their work.Wingham CourtPage 31 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · Service users benefit from a well run home. · Service users benefit from the ethos, leadership and management approach of the home. · Service users are confident their views underpin all self monitoring, review and development by the home. · Service users rights and best interests are safeguarded by the homes policies and procedures. · Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. · The health, safety and welfare of service users are promoted and protected. · Service users benefit from competent and accountable management of the service. Standard 37 (37.1 ­ 37.4) Y.A. & Standard 31 (31.1 ­ 31.8) O.P. The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care or equivalent? YES3 Key findings/Evidence Standard met? The registered manager is experienced and competent, with the skills necessary to run Wingham Court efficiently and to ensure that the needs of residents are met. She is a registered nurse who has managed the home for three years; she also has a certificate in management. Standard 38 (38.1 ­ 38.6) Y.A. & Standard 32 (32.1 ­ 32.7) O.P. The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? All interactions observed between the manager, staff and service users evidenced an open, positive and inclusive atmosphere.Wingham CourtPage 32 Standard 39 (39.1 ­ 39. 10) Y.A. & Standard 33 (33.1 ­ 33.10) O.P. Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? The home has a quality audit system in place; all aspects of the home are audited on an annual basis with some aspects being reviewed on a more regular basis, as need dictates. Service user satisfaction surveys are sent out by BUPA yearly, with the completed questionnaires being returned to an external company.Standards 40 (40.1 ­ 40. 6) Y.A. specific The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? Policies and procedures are in place and available to staff.Standard 41 (41.1 ­ 41. 3) Y.A. & Standard 37 (37.1 ­ 37.3 ) O.P. Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? A selection of records were seen. They were adequately maintained and stored securely.Standard 42 (42.1 ­ 42 . 9) Y.A. & Standard 38 (38.1 ­ 38.9) O.P. The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The manager is aware of the need to maintain a safe environment for service users and staff. Required policies, procedures and safety checks were inspected and seen to be in order to ensure so far as is reasonably practicable, the health, safety and welfare of service users and staff.Wingham CourtPage 33 Standard 43 (43.1 ­ 43. 7) Y.A. & Standard 34 (34.1 ­ 34.5) O.P. The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met? The homes current insurance certificate was displayed in the hallway. A budget plan was available.Standard 35 (35.1 ­ 35.6) O.P. Specific The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X2 Key findings/Evidence Standard met? No staff members act as appointees for service users. Service users personal allowances are dealt with by the home. Individual transaction records are maintained on computer. These transactions were not inspected as they were being audited at the time of the inspection. All of the service users monies are currently kept in one account. It is required that all services users monies are kept individually and not pooled.Wingham CourtPage 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Compliance Up to 30 beds may be used for rehabilitation of elderly post-stroke patients CommentsYESCondition Compliance Up to 16 beds may be used for respite and short stay care CommentsYESCondition Up to 3 beds may be used for palliative care CommentsComplianceYESCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateSarah Radlett Maggie WhiteSignature Signature SignatureWingham CourtPage 35 Public reports It should be noted that all CSCI inspection reports are public documents.Wingham CourtPage 36 PART DPROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSD.1 Registered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection. We are working on the best way to include provider responses in the published report. In the meantime responses received are available on request.We would welcome comments on the content of this report relating to the Inspection conducted on 30th September 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleWingham CourtPage 37 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. ,You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required NOAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planNONOOther: enter details here Wingham CourtPage 38 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Wingham CourtPage 39 Wingham Court / 30th September 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000013350.V173005.R01© This report may only be used in its entirety. 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