Inspection on 12/06/06 for Wisma Mulia

This inspection was carried out on 12th 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

Wisma Mulia 11/10/07

Wisma Mulia 06/06/07

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 Unannounced Inspection 12th June 2006 09:45 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.V298869.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. Wisma Mulia DS0000016654.V298869.R01.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 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.V298869.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th February 2006 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 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 £350 and £471 per week. Wisma Mulia DS0000016654.V298869.R01.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 commenced on one day in June 2006, with the site visit that took place over 7 hours 30 minutes. During this time the inspector spoke to a number of residents, one relative and staff working in the home to include the two senior carers and the manager. Three resident’s files were looked at in detail to include their medication records. Surveys were either completed during interviews with residents or their relatives, or were handed out to relatives/residents during and following the inspection and these results were later collated. A pre inspection questionnaire was sent out several weeks before the inspection and was returned and the information provided contributed to the report. 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. Comments from one survey received stated ‘I’ve enjoyed a thoroughly good time here for 30 years. We are extremely fortunate’. This statement appeared to sum up the feelings of every resident spoken with at the home. 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.V298869.R01.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. Wisma Mulia DS0000016654.V298869.R01.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.V298869.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. The home’s Statement of Purpose and Service Users Guide provide service users and prospective service users with details of the services the home provides enabling an informed decision about admission to the home. Satisfactory systems are in place to ensure prospective service users needs are assessed and assurance is given to them that the home can meet their needs. EVIDENCE: Amendments to the Statement of Purpose and Service Users Guide referred to in the last inspection, have been made and every service user spoken with confirmed that they had received a large file of information about the home and felt well informed. Four residents who had been admitted over the last year were all spoken with and confirmed that they had known of the home prior to admission and Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 9 requested it specifically or had looked around and /or experienced several homes, but chosen this as having the best ambience. One resident said she came into a room in Main House, which was all that was available at the time but moved to a flatlet about 6 weeks later. One reason for choosing the home was the proximity to the home where her husband lives and she is able to visit him on her ‘scooter’. She also remarked that when she moved in to the flatlet, she was able to choose the colour of the décor, which she greatly appreciated and it looked most attractive. Another resident also moved into a room awaiting a flatlet but has now settled into it and has no desire to move as the room feels like the home of her childhood. Most of the residents had either been admitted from hospital or another home, and in some cases, relatives had chosen the home. The senior carers spoken with said that generally one of them accompanies the manager when a pre admission assessment is made, using the assessment form to record initial details and building on this assessment after admission. An example of this assessment was seen. Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is judged to be adequate. This judgement has been made using available evidence including a visit to this service. The home has a care planning system in place to include an assessment of service users needs to ensure care plans are providing staff with adequate information to meet service users needs. Service users health care needs are fully met. Service users are not totally 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 EVIDENCE: With the help of an external consultant the senior carers are in the process of updating all the care files. Examples of the new files were seen and discussed during the inspection and three files were examined in detail. Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 11 Assessments are based on the activities of daily living, are detailed and give a good picture of an individual from which to identify problems and plan care. Actual and potential problems have been identified and will be reviewed monthly. The problems identified in some cases need to be more specific, for example rather than recording ‘mobility’ record that ‘someone is only able to walk short distances with assistance’. It was also discussed that when there is no problem identified then forms such as fluid balance charts do not need to be included. The care plans seen reflected the needs of those residents spoken with. At present ‘daily records’ are not kept daily, but are used to record any significant event. However, these recordings are not followed up so if one day it was reported that someone is unwell, there is no other record to state if they recovered or what action was taken. There are plans to commence daily recording in future, which should also improve communications, which some staff perceive as a problem. There is evidence to confirm that regular reviews are completed but no written evidence as yet to suggest that these are completed with the resident or their relative. However, the one relative spoken to stated that they are kept fully informed about their mother’s condition and the senior carers explained that the new care planning system has a specific form for reviews with space for the resident or their relative to sign and this was seen. Risk assessments and moving and handling assessments are completed and reviewed regularly. It was discussed that there must be close monitoring for any residents with memory problems who may wander out of the grounds and also for those residents living in the first floor flats, as changes in their conditions may warrant a change of accommodation. It was confirmed that this had already occurred with one resident who has since moved to a ground floor room in the main house. From surveys completed, records seen and speaking with staff and residents there is confirmation that residents are referred to other agencies as necessary. The home is registered with the one local practice and doctors will visit as necessary, as do community nurses. The Macmillan nurses are currently attending one resident and it was mentioned that the physiotherapist also sees some residents where necessary. Two residents spoke of their hospital appointments; one attended the morning of the inspection. Medication is dispensed from the local doctors practice however it was noted that following the practice instructions only one bottle of certain medications such as aperients is ordered in the name of one resident and used by them all. This is not an acceptable practice and must cease. The Commission pharmacist for the area has been informed and may visit to give further guidance. Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 12 The medication trolley is locked and attached to a wall as required in a cupboard in the meeting room; any controlled medication is stored appropriately within a double locked cupboard as required within the staff room. It was noted that some internal and external medications are stored together, which is not recommended practice. Medication records were examined; these are typewritten by the administrator and senior care staff check and make note of any changes to be made. There were a few inaccuracies in the names of some medications and in one instance milligrams (mg) was recorded rather than micrograms (mcg). It would be good practice for the two senior care staff to check all medication charts once typed and both sign once checked that all the transcriptions are accurate. There were also a few gaps in recording that needed to be followed up and a slight confusion over codes being used when medicines are not taken. There are several residents in the home who self-medicate and lockable facilities are provided for this purpose. These residents sign a form to state that they will take responsibility for their medication and risk assessments are completed. It was advised that where self-medicating this should be indicated on the care plans to ensure they are reviewed regularly. Staff were observed knocking on doors of residents rooms before entering and addressing residents with respect. All the residents have their own door keys to afford maximum privacy and everyone is able to see their relatives/friends in private. Wisma Mulia DS0000016654.V298869.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. Activities provided in the home aim to cater to individual needs of the residents providing them with meaningful ways of spending their time. Residents were able to choose their daily routine. Service users maintain contact with family, friends, representatives and the local community as they wish and are helped to exercise choice and control over their lives. The meals in this home are good offering both choice and variety, and catering for special dietary needs. EVIDENCE: Since the last inspection the creation of an art room from a former garage has been much welcomed by several residents who enjoy various forms of painting to include silk paintings. An art teacher visits the home once a week. A number of the residents are members of Subud from which Wisma Mulia was founded. It is an international nondenominational religious association and the home has its own hall of worship, which is used for Subud members but also for other religious services and social occasions such as slide shows and Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 14 visiting speakers. Television, video and audio equipment are also available in the communal areas. Newspapers are provided in the sitting room. The home is a short distance from the village where there is a post office, store and inn and the bus stop is outside the home. The home also has a house driver and vehicle, which is available each weekday until 1 pm and is used for outings and hospital and other appointments. On the day of inspection a number of residents and staff were enjoying the spacious and well-maintained gardens and there is a summerhouse and sturdy garden furniture available. Staff and service users spoken with related that they now have a coffee morning and shop selling items such as sweets and toiletries every Wednesday. This is proving very popular. There was also a clothing sale the previous week. Sherry mornings are held every first Sunday and wine is served with lunch every Sunday now. Some care staff organise quizzes for any residents who wish to take part, often during the evenings, and board games are available. Barbecues and other entertainment are also organised and an outing arranged each month. These tend to be quite local now, to garden centres etc., but a trip on a long boat took place recently and there have been some shopping trips to Cribbs Causeway in Bristol. Five residents went to visit a house and garden at Malvern the previous weekend and one said what an enjoyable day it had been One resident summed it up by saying ‘there is always something to do’. 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. It was noted that a tray of beverages was available in the lounge. Where necessary visitors can also be offered accommodation if they wish or need to stay overnight, as the relative spoken with had been doing. 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. Most of the residents spoken with said the meals were very good and they enjoyed them. Lunch on the day of inspection was chicken pie with a variety of vegetables, followed by stewed apple. Menus are on display in the conservatory and were provided for the inspection. In addition to the main meal is a ‘special’ such as a vegetarian option. One resident said the meals were delicious with very exotic sweets, but yoghurts and fruits were always offered as alternatives. Supper is a buffet style meal that can be eaten in the dining room or a choice collected and taken to their rooms. The buffet supper seen during the inspection looked extremely appetising. Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 15 The kitchen was briefly viewed during inspection and new worktops have been installed. All appeared to be clean and well organised. Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 16 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): 16,18 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure in place and residents and their families feel confident that concerns are listened to and acted upon. The home has arrangements in place to ensure service users are not at risk of harm or abuse. EVIDENCE: The pre inspection questionnaire returned by the manager stated that the home had not received any complaints since the last inspection. The complaints procedure has been amended as recommended in the last inspection. Every service user spoken with and surveys received confirmed that they were all very aware of how to complain and who to complain to. They all had complete confidence in the manager who they said ‘would do anything for you’ ‘was so kind to everyone’ and ‘worked very hard, so they didn’t want to bother him unnecessarily’. One had complained at the previous inspection about draughty windows and cleanliness. She reported that they have looked into doing something with the windows, possibly double glazing but have to take into consideration that it is a listed building before deciding on anything; Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 17 however, as the temperature is 75° downstairs and 80° upstairs at present this is not so much of a problem. She also reported that she was still dissatisfied with the cleaning but an arrangement has now been made to have the services of two cleaners on one day a week to ensure the accommodation is cleaned, which will hopefully resolve this matter. Most of the staff received training in Protection of Vulnerable Adults in May 2006 and staff spoken with confirmed this and said how enlightening they found it. From the training matrix provided there are still 12 staff who have yet to attend this, and all staff should receive regular updates. Further training is being arranged. The home also has policies and procedures in place for protecting vulnerable adults, which have been reviewed since the last inspection. Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 18 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): 19 & 26 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. The standard of the environment in this home is good providing service users with an attractive and homely place to live. EVIDENCE: A part tour of the home took place with some service users flatlets and rooms inspected. All of the residents seen were happy with their accommodation, which was comfortably furnished, mainly with their own furniture, and in good decorative order. The general cleanliness of the home is good, with just one service user again commenting on the standard of cleanliness (see standard 16), but a resolution appears to underway. There are normally three domestic staff but one was on leave at the time of inspection and none were spoken with on this occasion. Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 19 It was reported that extra cleaning has been obtained by changing night duties to cleaning and laundry now being done by one person during the day. Care must be taken to ensure that non- care tasks do not compromise care duties during the night. Some of the residents spoken with did say that they wish to remain as independent as possible and do some of their own cleaning and make their own bed, but provisions have to be in place to give a good service, as they may not always feel like, or be able to do any of these tasks themselves. One service user also felt that some of the carpets in her accommodation were becoming worn and should be replaced. This was fed-back to the manager. It was reported that the hall had been redecorated and new furniture and curtains are under consideration. A maintenance plan is in place for future redecoration and refurbishment projects, to include work on the cottage and annexe. Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 20 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): 27,28,29,30 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the numbers and skill mix of staff and are in safe hands at all times. Training opportunities have been provided for staff to improve their skills and staff are trained and competent to do their jobs. Service users are now supported and protected since the standard of vetting and recruitment practices has improved with the appropriate checks being carried out. EVIDENCE: Care staff on –duty from 8 am to 3 pm during the inspection consisted of three care staff; from 3 pm to 5 pm there were two care staff, from 5 pm to 8 pm three care staff and from 8 pm to 8 am two care staff. In addition to this a laundry assistant, two cleaners, a cook and kitchen assistant were also onduty. The two senior carers were supernumerary and working on the review of all the care plans. The senior carers and one other carer were spoken with during the inspection. Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 21 It was discussed that with the increasing dependency of the residents, there are occasions such as when one resident is unwell and needs the attention of two carers that staff need to be increased. It was confirmed that this has happened in the past and would continue. All residents spoken with and surveys received confirmed that the care staff carried out their duties competently and fully met the needs of the residents. A training matrix was provided showing what training each member of staff has received and that all but one member of staff, who is currently off sick, has received some training in the past two years. Eleven care staff have completed either NVQ 2 or 3 and two domestic staff have also completed NVQ 1. Some staff who have completed NVQ 2 would like to go on to do NVQ 3 but it was reported that the college would no longer accept staff to do so unless they are in senior care positions. In addition to mandatory training one carer spoken with confirmed she had attended training on dementia awareness, medications, infection control and aggression in the workplace. Some of these courses are completed through distance learning. Several staff files were seen to include one newly appointed member of staff. All appropriate paperwork is now in place for any newly appointed staff to include full carer history and medical questionnaire, three written references, one being from the last employer, and CRB and POVA First check. The newest recruit does not have a CRB check yet but has a POVA First check and is working under supervision. It is advised that a risk assessment is also completed and held on file to justify why this person has started work prior to CRB clearance and to identify safeguards taken. The home has been reminded to keep CRB disclosures of new employees until seen at the next inspection and then they can be destroyed. A record of interview was seen but needs to be formalised for equal opportunities and the current induction programme is under review. Staff files were also seen to contain contracts, job descriptions and job specifications. Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 22 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): 31,33,35 & 38 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. 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 responsibilities fully. The home is run in the best interests of service users. Service users financial interests are safeguarded. The health, safety and welfare of service users and staff is promoted and protected. EVIDENCE: The manager has been approved and registered by the Commission since the last inspection. He is a qualified social worker with experience of running and owning care homes in the recent past and is currently undertaking NVQ 4 registered managers award. Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 23 All of the residents spoken with were very satisfied with the way he manages the home and his willingness to do all he can to provide a good quality of life for everyone living there. Each of them gave examples of ways that he had helped them and all feel that he has an open door policy and feel able to discuss any concerns with him. This was observed during the inspection. Staff spoken with confirmed this and said that he was receptive to new ideas. Since he came to the home they have had several meetings (minutes seen) and access to training has improved enormously. When asked of one thing that could improve the home, one carer replied ‘communications’ and explained that although they have staff handovers each day and have a communication book, some things that may have been dealt with through the office do not get passed on and at weekends staff are not always able to answer relatives queries. It was suggested that keeping of daily records and keeping them in a more accessible place, rather than upstairs should improve this. Minutes of residents meetings were also seen. The manager has introduced a number of in- house audits and results of these were seen and include accidents, the kitchen, training, pharmacy, nutrition, and care plans. In addition to this, surveys were given to residents/ relatives and other agencies such as doctors, district nurses etc over the last year and results are being collated and published as part of the service users guide. A summary of the survey completed in February 2006 was provided. This needs to also indicate any actions taken as a result of the findings and the process should continue on a regular basis. Records and receipts are in place for the personal money held for one service user. The home does not deal with the finances of any resident in the home. Evidence was seen of fire alarm testing and emergency lighting testing being carried out regularly. A maintenance schedule was seen and this listed the dates of the servicing of equipment. Electrical wiring checks are currently being undertaken and portable appliance testing is in future being arranged once a year rather than on a rolling programme through the year. Since the last inspection risk assessments had been completed for service users who have kettles in their rooms. It was discussed that the same should apply to microwaves and refrigerators to ensure that out of date food is not kept and used and that food heated in a microwave is heated to the correct temperature. Other potential risks noted were the corridors on the ground and first floor of the flatlets, which as exposed to the elements can be very cold during the Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 24 winter months and can result in wet and potentially slippery tiles, which could be very hazardous to anyone walking along there. Another less obvious risk could be to anyone who may lean over the wall from the upper floor and risk falling. Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 25 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 X 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 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 2 Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 13 Timescale for action The registered person shall make 31/07/06 arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the house. The registered person shall 31/07/06 ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety and that unnecessary risk are identified and so far as possible, eliminated. Requirement 2 OP38 13 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 OP7 Good Practice Recommendations Daily records should be kept to aid communication and to indicate actions taken; Problems to be more specific; DS0000016654.V298869.R01.S.doc Version 5.2 Page 27 Wisma Mulia 2. OP9 3. 4. OP9 OP9 5. OP9 6 OP38 Only use records that are relevant to the individual’s problems. Medicine policies in the home should include the guidelines from the Royal Pharmaceutical Society of Great Britain’ 2003. ‘The Administration and Control of Medicines in the Care Home’ and the Medicines Act. Store all internal and external medicines separately. The registered manager to seek information and advice from a pharmacist regarding medicine policies within the home and medicines dispensed for individuals in the home. Handwritten or typewritten medication transcriptions should be checked and signed by two authorised staff trained in medication, that the charts are accurate before use. The home should complete risk assessments for all aspects of the service users lives in the home, where a potential risk has been identified. Wisma Mulia DS0000016654.V298869.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Wisma Mulia DS0000016654.V298869.R01.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. 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