Inspection on 11/10/07 for Wisma Mulia

This inspection was carried out on 11th October 2007.

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

Other inspections for this house

Wisma Mulia 06/06/07

Wisma Mulia 12/06/06

Wisma Mulia 24/02/06

Wisma Mulia 08/08/05

Wisma Mulia 18/01/05

Wisma Mulia 20/07/04

Wisma Mulia 18/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Wisma Mulia Bridge Road Frampton-on-severn Glos GL2 7HE Lead Inspector Mrs Janet Griffiths Key Unannounced Inspection 10:00 11 & 12th October 2007 th 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 Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wisma Mulia Address Bridge Road Frampton-on-severn Glos GL2 7HE 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) 01452 740432 01452 740084 Fountain Housing Association Limited Mr Philip L James Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Sensory impairment (5) of places Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2007 Brief Description of the Service: Wisma Mulia is a care home situated in the village of Frampton-on-Severn. The secluded gardens surrounding the home give both peace and privacy to the service users who live there. The core philosophy of the home is based on a spiritual following called Subud. This is an association of people of all races, religion and creeds. Its foundation is the simple worship of God without dogma or teaching. This does not preclude anyone from living there. The extension to the main house comprises of single flatlets and double flatlets on the ground and first floor served by a shaft lift. The ground floor flatlets have French doors and paved patio areas. The main house has six single, ground and first floor bedrooms. There is also a separate coach house. Communal areas on the ground floor consist of a lounge, dining room, solarium and a spacious room used for prayers and activities. The gardens are well kept and include a fountain and seating area. Information about the service to include CSCI reports is made available by the provider to prospective service users through the homes’ Statement of Purpose and Service Users Guide. At the time of inspection the fees are between £365 and £490 per week. Additional charges are made for hairdressing, chiropody and newspapers. People funded through the Local Authority have a financial assessment carried out in accordance with fair access to Care Services procedures. Local Authority or Primary Care Trust charges are determined by individual need and circumstances. General information about fees and fair terms can be accessed from the Office of fair trading web site at www.oft.govuk http:/www.oft.gov.uk Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This unannounced key inspection site visit took place over seven hours and thirty minutes on two days in October 2007. During this time the inspector spoke to several residents, staff working in the home and the manager and deputy manager of the home. A tour of the premises did not take place on this occasion but communal areas and several of the residents’ rooms/flatlets were seen. Five resident’s files were examined in detail to include their medication records. Other records examined included staff recruitment and training records, staff supervision records and maintenance records. An Annual Quality Assurance assessment form has been sent to the home but has not yet been completed although the manager is working on this. Staff and service user surveys were also left at the site visit to be distributed and comments received from them will be included in this or a future report. This is the second key inspection carried out this year. CSCI Pharmacy Inspector also carried out a random inspection earlier this year because of concerns over medication procedures. What the service does well: The home offers a calm, peaceful and homely environment in which to live and all of the service users spoken with said how contented they were living at Wisma Mulia and what a good quality of life they had. The home aims to maintain the independence of the residents for as long as they are able and the provision of a number of flats where the resident has their own kitchenette contributes to this. Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3. Standard 6 not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families have all the information they need to make an informed choice regarding placement at the home and pre-admission visits take place to carry out an assessment and ensure that needs can be met. Residents normally move in on a long-term basis therefore Std. 6 was not assessed. Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 9 EVIDENCE: There had been two new admissions since the last key inspection in June. Both of these residents were spoken with and their records examined. Although the manager and administrator stated it is their policy to give service users guides to each new resident and were certain they had done so, the one resident spoken with could not recall seeing a book of any information being given to her. This was fed-back and further information provided. Both had had pre-admission assessments completed, and were seen, although one had spent two weeks respite care at the home prior to admission to see whether she would like to stay there permanently. She is pleased with her decision and that she made it herself. The manager, where possible is encouraging relatives to provide a profile of each service user with facts such as past interests and people who are important to them. Several of these were seen in file and were most informative. Contracts were seen and had been signed. Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate however, one area, standard 9 gives some cause for concern (see below). These judgements have been made using available evidence including a visit to this service by the key inspector and pharmacy inspector. People who live in this home have their health care needs met through individually planned care that clearly set out needs and how they are met, to include healthcare referrals and interventions where required. They are also treated with respect and their privacy and dignity are protected. There are marked improvements in the arrangements for managing medicines although there are a few small issues to address in order to ensure the safety of people in the home. Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 11 EVIDENCE: To date the two senior care staff have been responsible for carrying out assessments and compiling care plans for each service user and this has been completed well in most cases. Each resident is allocated a key-worker who among other things is responsible for their care plan reviews completed with them and/or their relatives. There is evidence that these are being completed, but there have been problems with staffing recently and several staff have left, so some reviews are overdue. A total of five care files to include those of the two most recently admitted service users were examined. All had assessments completed. Most were quite detailed but one of the new ones had not yet been completed. Care plans were in place for all but the two new service users, reflected current needs and were reviewed, but not all were dated and none signed as there did not appear to be a space on the paperwork for a signature. Moving and handling and other risk assessments were completed on all but the two new service users; one of these was having some difficulty showering because of the position of the rail on the wall. It was suggested this was moved but also a risk assessment should be completed in this case. The district nurse is attending one service user at this time and within the records referral to multi-disciplinary agencies such as dietician, physiotherapist, doctors and nurses was made. One doctor from the local practice visited during the inspection. Arrangements are also made for residents to visit their own dentist, optician, chiropodist if they prefer that to someone coming to the home to see them. One resident has had a long-term dietary problem, which the home has taken great strides to accommodate, all to no avail. A food consultant was hired earlier in the year to advise the cook in healthy eating menus and these have been incorporated into the menus but the problem persists and no resolution is foreseen. Several of the residents have become very frail and are now nursed more often in bed, but have special beds and mattresses and pressure relieving cushions when sat out. A portable hoist is also in use for moving and handling procedures. Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 12 A deputy manager was appointed a month prior to the inspection and part of her role is to carry out medication audits in view of past problems with the medication records and administration in the home. All of the medication records and medications were examined during the inspection and most records on this occasion were accurate. There were only a couple of gaps in recording found and these are being closely monitored and followed up with the person responsible. There was only one discrepancy of timing of one medication between what instructions were given on the box and what time the drug was given and only one where there was no specific instruction on when a tablet should be given on the packet. There was just one instance where 4 doses of a tablet had been signed for but only three removed from the packaging. Overall there was a marked improvement. However the medication trolley was very cluttered and overloaded with medication pots and a variety of other things, and sticky bottles inside which should be wiped with a damp cloth after use. It was also noted that staff have a tendency to open a new box or foil containing tablets before using the one already in use, which is not acceptable to provide good stock control and there is a danger that medicines may go out of date. It was noted that all medicines are dated on opening which does help the audit trail. The home has no controlled drugs held; a new controlled drugs register has been obtained and as there are plans to move all the medications into a specially created clinical room in the near future, no alterations have been made to the controlled drug cupboard. Storage arrangements must be improved with some urgency as stock medication is held in a most unsuitable cupboard under the stairs, where staff have to almost kneel down to access it. Further medication cupboards to include the controlled drug cupboard are situated in the staff room; any eyedrops or medication that require refrigeration are now held in a locked and secured box in the kitchen refrigerator; records of receipt and disposal are in a locked cabinet outside the office and the medication trolley is situated in the homes’ Latihan Hall where Subud members hold their prayer meetings. A number of staff have just received an update on medication training and those spoken with said that it was very good. There are still a number of staff who have had training in the past (not all had visible certification to confirm this) and will need updates this year. Observations during the visit and speaking with service users confirmed that their privacy and dignity is respected with staff knocking on doors prior to entering rooms and residents being addressed as they wish to be addressed. Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home are supported to realise their own preferences and expectations, both in the home and in the community and are able to maintain contact with friends and family. They also receive a wholesome, appealing and balanced diet in pleasant and comfortable surroundings. EVIDENCE: Many of the residents who live at Wisma Mulia are fairly independent and continue their own interests wherever they can. Staff organise activities and social events which include shopping trips, often on a one to one basis, excursions such as boat trips and seasonal visits to see local beauty spots etc, Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 14 summer picnics, barbecues, village coffee mornings and visits by musical groups, talks and Subud members. A mobile library provides a good supply of reading materials and the hairdresser visits each week. Facilities provided include an art room, an in-house shop, a Latihan hall (used for Subud meetings among other things) and a home cinema. An art class is about to commence and a music and drama group has also been introduced lately and is enjoyed by some residents. One of the new residents was happily enjoying a game of patience in the lounge on the first afternoon of the visit and was reading her paper in the morning. Many of the residents enjoy walking around the garden, and some venture further, to the end of the drive and even towards the village or canal. Visitors are made welcome at any time of the day or evening and beverages are offered. Most residents also have facilities for tea/coffee making in their rooms if they wish and their visitors may join them for meals having made prior arrangements with the kitchen. Where necessary visitors can also be offered accommodation if they wish or need to stay overnight. A choice of light breakfast such as cereals, porridge, toast, fruit and fruit juices are available each morning in the residents’ rooms. Those who are able may prepare their own in their kitchenettes. Coffee is also served in their rooms and flasks are available, then lunch is served at 1 pm. Most people eat in the dining room, but they may stay in their rooms if they wish. Supper is a buffet style meal that can be eaten in the dining room or a choice collected and taken to their rooms. Meals served on both days of the inspection looked and smelt very appetising. Special dietary needs are catered for and supplements are provided when intake is poor. Food and fluid charts were noted in one resident’s room. One resident requires full assistance with meals but reportedly eats very well. Others just require a little help or prompting and staff join them in the dining room at mealtimes. Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People in the home are protected by the systems in place. EVIDENCE: The home has a complaints procedure included in the service users and reference is made to the Commission for Social Care Inspection within this. People spoken with indicated that they know what to do if they had a complaint and as the manager has an ‘open door’ policy there is a constant stream of residents who pop in to ask questions or to express concerns when they have any. It was reported that there have been no complaints since the last inspection although the constant dissatisfaction one service user has with any food offered was discussed and is fully documented in their records. The inspector is satisfied that the home has taken all the steps they can to accommodate this but it appears that there are probably underlying health problems related to this, which the home are unable to solve. Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 16 The home has policies on abuse and whistle blowing. They refer to the document ‘No Secrets’ and the Alerter’s Guide. Staff also receive training on Protection of Vulnerable Adults, confirmed by the training matrix provided. Staff spoken with enjoyed their training on Protection of Vulnerable Adults and all appeared to be aware of the processes involved. Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained, clean and hygienic throughout. Equipment is provided to aid mobility and promote independence. Individual bedrooms are decorated and equipped to meet the needs of their occupants. EVIDENCE: As the home was inspected in June a tour of the premises did not take place on this occasion but several rooms/flatlets were seen in the course of visits to service users, as were most of the communal areas. All areas seen were clean, odour free and well maintained. Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 18 Since the last inspection the kitchen has been redecorated and the refurbishment is completed. Plans are underway to replace the dining carpet, which despite regular cleaning was again stained on this occasion. There are also plans to extend the solarium next year to increase the communal space in the home and to make improvements to the car parking, possibly moving it away from the front door. No rooms have been redecorated since the last inspection but all appeared in good decorative order and would be redecorated on a rolling programme if a need was identified. A new maintenance man has commenced since the last inspection working three days a week. He was not working during the inspection. Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home generally have their needs met by sufficient skilled staff who are able to meet the needs of the current number of people living at the home, although in recent months they have experienced some staffing difficulties. It is hoped that with new recruitment this situation will improve. They are also protected by the homes recruitment system. Staff are supported to undertake regular and relevant training. EVIDENCE: It was reported that over recent months with annual leave, sickness and several staff leaving, the home has struggled a little to maintain staffing levels. However, with the recent recruitment of a deputy manager and imminent appointment of several new care staff it is hoped that this situation will improve soon. Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 20 Nonetheless, no service users spoken with raised concerns about deficient staffing levels and there appeared to be a calm and unrushed atmosphere within the home. Staff spoken with did however voice some concerns about rising dependency levels and shortages of staff on some occasions. At the time of inspection there were three care staff and the manager on during the morning and afternoon shifts but because of sickness the deputy manager was called in to cover a couple of hours during the afternoon and an agency carer was on-duty the second morning. Night duty also had to be covered. In addition to care staff there was a cook, a kitchen assistant, a laundry assistant, a cleaner and the administrator on-duty Six staff files were examined on this occasion; two of staff newly appointed and the remainder of staff who have been interviewed and are awaiting CRB checks and references before being given a start date. Of the two already appointed all the required paperwork and checks were in place with the exception of a photograph and an interview record in one case. The correct procedures were in place for the recruitment and appointment of the other new staff. The deputy manager is currently reviewing the induction programme, based on Skills for Care, and this was discussed. A copy of the training matrix with details of all recent staff training was provided and includes POVA training, fire training and food hygiene last year and medication training this year. To date approximately 6 staff have completed medication training updates and further arrangements are to be made for the remainder of staff responsible for medication administration to have an update of their training. It was also noted that according to the training matrix no-one appeared to have had moving and handling training updates since 2005. These must be updated annually. Fourteen staff now have NVQ 2 or 3. Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 33,35, 36, & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live in the home have their best interests met by the manager and staff who are committed to their responsibilities. They and the staff are generally protected by the health and safety systems in place in the home but fire safety within the home needs to be more robust. EVIDENCE: Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 22 The manager is a qualified social worker with experience of running and owning care homes in the recent past and has almost completed NVQ 4 registered managers award. Staff and residents spoken with all confirm that he has an ‘open door’ and it was observed that he was easily accessible to residents when on-duty with someone always ‘popping in’ with a query. Some staff however, still feel that things don’t always get done and feel that he possibly ‘ has too much on his mind’. It is hoped that with the appointment of the deputy this situation should improve. Staff and resident meetings are held and minutes recorded and made available for anyone unable to attend. The next staff meting is the week following the inspection and the last residents meeting a couple of weeks. Minutes were not seen on this occasion. With the appointment of the deputy manager staff appraisals have commenced and a supervision programme is now in place. Some staff confirmed that they had recently had their appraisals and some records seen confirmed this. Daily records are being kept and these are full and informative and demonstrate action taken when a problem has been identified. Satisfaction surveys are carried out annually. They were due to go out earlier this year but because of other pressures have not gone out yet. In addition to this the manager carries out a number of other audits to include care plan, medication, accident, nutrition and kitchen audits and mandatory and specialist training. The deputy manager is reviewing the existing medication audit paperwork in order to have more effective documentation but has already completed an audit on the medication records, which are to be constantly monitored. Residents finances are generally their own or their families responsibility and the home does not act as appointee to any resident. Records were also seen to confirm that regular maintenance and servicing of equipment is carried out, to include legionnaires water testing, lift and hoist servicing. Fire equipment is also serviced regularly but as the home was without a maintenance man for a while records indicate that the fire alarms and lighting have not been tested since August. It is recommended that fire alarms are tested weekly and lighting monthly. It also appears from the training records that there has been no fire training this year. It was reported that the fire safety officer has visited and more work needs to be done to complete the risk assessment which must look at, together with staff training, an evacuation Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 23 process. New fire regulations state that a ‘stay put’ policy is no longer acceptable. It was also noted that a number of rooms had their fire doors wedged open and again this is unacceptable and puts both staff and residents at risk. Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 2 Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1-2) Requirement A service user plan of care from a comprehensive assessment must be drawn up for each resident and must be reviewed at least monthly with the service user/their representative where possible. Arrangements must be made to ensure accurate recording, and safe handling, safekeeping and safe administration of medicines within the care home, through constant auditing processes. This is an outstanding requirement from the last inspection and the timescale of 31/08/07 has not been met in full. When staff are involved with the handling and administration of medication they must be properly trained and regularly assessed as being competent to perform these tasks safely. This is an outstanding requirement from the last inspection and the timescale of 31/08/07 has not been met in full DS0000016654.V348634.R02.S.doc Timescale for action 30/11/07 2. OP9 13(2) 30/11/07 3. OP9 18 31/12/07 Wisma Mulia Version 5.2 Page 26 4. OP30 18(1)(c) 5. OP36 18(2) 6. OP38 23(c) The registered person must ensure that all newly appointed staff received structured induction training, to include mandatory training such as moving and handling and fire training and all other staff receive annual updates. This is an outstanding requirement from the last inspection and the timescale of 31/08/07 has not been met in full All persons employed in the home must be appropriately supervised and a record kept of this supervision. This is an outstanding requirement from the last inspection and the timescale of 31/08/07 has not been met in full After consultation with the fire authority ensure adequate arrangements are in place for reviewing fire precautions and testing fire equipment at suitable intervals and for the evacuation in the event of fire, all persons in the care home and safe placement of service users. Make arrangements for all persons working at the home to receive suitable training in fire prevention and ensure through fire practice/drills that staff are aware of a safe evacuation process. 31/12/07 31/12/07 30/11/07 7. OP38 23(d) 30/11/07 Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 27 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 OP9 Good Practice Recommendations Fix the controlled medicine cupboard so that it is secured in accordance with The Misuse of Drugs (Safe Custody) Regulations 1973. Provide a properly printed and bound record book to keep records when these medicines are used. All new members of staff should receive induction training to Skills for Care specification. Care staff should receive formal supervision at least 6 times a year. 2. 3. OP30 OP36 Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wisma Mulia DS0000016654.V348634.R02.S.doc Version 5.2 Page 29 - 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!