Inspection on 24/02/06 for Wisma Mulia

This inspection was carried out on 24th February 2006.

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

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

Other inspections for this house

Wisma Mulia 11/10/07

Wisma Mulia 06/06/07

Wisma Mulia 12/06/06

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 Sharon Hayward-Wright Unannounced Inspection 10:10 24 February 2006 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.V277623.R01.S.doc Version 5.1 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.V277623.R01.S.doc Version 5.1 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 Mrs Helen Rowe-Taylor 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.V277623.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2005 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. Wisma Mulia DS0000016654.V277623.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5 hours on one day in February 2006. Seven service users were spoken with to gain their views on the home and the care of three service users was looked at in detail. Four staff members were also spoken with. Staff were observed going about their duties and interacting with each other and service users. The requirements and recommendations issued at the last inspection were followed up and records relating to care, complaints, training and maintenance were examined. Three requirements remain outstanding since the last inspection and must be addressed. A warning letter has been sent for the home to address the issues around pre-employment checks. Service users spoken with all praised the home saying they are happy living there. What the service does well: The service users either have their own flatlet or large room in the main house that are in excess of the recommended spacial requirements mentioned in the National Minimum Standards for Older People. The meals in the home are good offering both choice and variety and catering for special dietary needs. 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. However some additions are needed to ensure the guides meet the requirements. Wisma Mulia DS0000016654.V277623.R01.S.doc Version 5.1 Page 6 The standard of the environment in this home is good providing service users with an attractive and homely place to live. 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.V277623.R01.S.doc Version 5.1 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.V277623.R01.S.doc Version 5.1 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 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. However some additions are needed to ensure the guides meet the requirements. Satisfactory systems are not place to ensure prospective service users needs are assessed and assurance is given to them that the home can meet their needs. EVIDENCE: Since the last inspection the home has sent revised copies of their Statement of Purpose and Service Users Guide to the Commission for Social Care Inspection. However both guides require amendments to their complaints policy as a time limit of 28 days must be added for the final response to a complaint. The Service Users Guide requires a copy of the homes terms and conditions and contract. Wisma Mulia DS0000016654.V277623.R01.S.doc Version 5.1 Page 9 Otherwise these guides contain information for service users and prospective service users on what services are offered at the home. The care plans of a service user admitted to the home since the last inspection was examined. The inspector was not able to find a pre admission assessment of this service user’s needs. A requirement was issued at the last inspection for the home to ensure service users are not admitted to the home unless their needs have been assessed by a suitably qualified person. Wisma Mulia DS0000016654.V277623.R01.S.doc Version 5.1 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&9 The home has a care planning system in place, however an assessment of service users needs is required to ensure care plans are providing staff with adequate information to meet service users needs. The home has made good progress with regard to the arrangements for safe storage of medication during administration. EVIDENCE: The care of three service users was examined in detail. A requirement issued at the last inspection for service users to have an assessment of their needs undertaken and kept under review has not taken place and has been repeated again. From the care plans and from speaking with staff and service users proved the care provided was current, however one of the service users care plans had not been reviewed since November 2005. Other care plans examined had been reviewed monthly. Risk assessments are in place, however this service user’s had not been reviewed since November 2005. A recommendation made at the last inspection for the home to undertake risk assessments for the prevention of falls has been repeated again. Wisma Mulia DS0000016654.V277623.R01.S.doc Version 5.1 Page 11 Moving and handling assessments for these three service users were in place and reviewed. Evidence was seen of service users involvement in their care plans. Medication was not examined in detail only a requirement issued at the last inspection and this has been addressed. Wisma Mulia DS0000016654.V277623.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The meals in this home are good offering both choice and variety, and catering for special dietary needs. EVIDENCE: A full inspection of the kitchen was not undertaken, as the home has recently had an Environmental Health visit. A number of requirements were issued. The cook said the kitchen is going to be refurbished very soon. A requirement issued at the last inspection has been addressed. The cooks devise the menus. Records of food were not examined at this inspection. One service user said that the home is able to meet her special dietary needs. Service users spoken to all said they enjoy the food provided and alternatives are offered if required. Service users are able to make their own hot drinks in their flatlets. Wisma Mulia DS0000016654.V277623.R01.S.doc Version 5.1 Page 13 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 The home has a complaints procedure in place, however to date there is no evidence that service users concerns are listen to and addressed. The home has arrangements in place to ensure service users are not at risk of harm or abuse, however the home needs to ensure these are up to date. EVIDENCE: From discussions with a senior carer she did not know if the home had received any complaints. One service user said she has concerns about the cleanliness in the coach house where she lives. She also said the windows are draughty. The senior carer said they are aware of these issues but no records were available. These concerns were forwarded on to the Responsible Individual as the Manager is away. The home needs to amend their complaints procedure as directed in Standard 1. The home has policies and procedures in place for protecting vulnerable adults, however several of these polices have not been reviewed since 2002. These must be reviewed to ensure they are up to date with the latest legislation. A member of staff said they have undertaken abuse training as part of their NVQ 2 training. The home is looking to arrange training for staff in this subject. Wisma Mulia DS0000016654.V277623.R01.S.doc Version 5.1 Page 14 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 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. Service users spoken to all said they liked their room/flatlet and they were warm enough. The general cleanliness of the home is good and only service user reported concerns about the cleanliness of their rooms (see standard 16). Three domestic staff were spoken to and they said they have a cleaning schedule in place. The home has recently added two sluice machines, one in the laundry and one in the staff toilet. The one in the staff toilet is waiting for screening to be put in place. The laundry was upgraded prior to the last inspection and no issues were identified at this inspection. Staff were seen wearing protective clothing when required. Wisma Mulia DS0000016654.V277623.R01.S.doc Version 5.1 Page 15 An art room is in the process of being finished and one service user spoken with said she is looking forward to using the room. The home is planning to refurbish the kitchen shortly. Wisma Mulia DS0000016654.V277623.R01.S.doc Version 5.1 Page 16 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): 28, 29 & 30 Training opportunities have been provided for staff to improve their skills but there are inconsistencies with not all staff receiving training. Since the last inspection the standard of vetting and recruitment practices has not improved with the appropriate checks not being carried out and potentially leaving service users at risk. EVIDENCE: Eight staff have the NVQ 2 training and five staff are undertaking the course. One staff member is undertaking the NVQ 3 training. The homes training matrix was examined. There were a number of gaps against some staff. Food and hygiene training was taking place during the inspection. The home needs to ensure that staff receive training appropriate to the tasks they are to perform. The senior carer in charge said she was going to arrange some training with the person teaching the food and hygiene training. The training matrix said that staff had not received fire training since April 2005 this must be addressed. Six personnel files of recently appointed staff were examined. Only one of these contained the required pre-employment checks as directed by the Care Homes Regulations. This requirement remains outstanding at previous inspections and must be addressed. A warning letter has been sent. Wisma Mulia DS0000016654.V277623.R01.S.doc Version 5.1 Page 17 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): 38 The health, safety and welfare of service users and staff is promoted and protected, however there was no evidence in place to prove all safety checks on equipment in the home is taking place. EVIDENCE: Standard 33 was not inspected in full, as the Manager was not at the home these will be followed up at the next inspection. Evidence was seen of fire alarm testing and the systems but the last documented check of the emergency lighting was 16/10/05. The home must ensure these take place at least monthly as directed by the fire service. A maintenance schedule was seen and this listed the dates of the servicing of equipment. Water temperature checks were seen. Wisma Mulia DS0000016654.V277623.R01.S.doc Version 5.1 Page 18 Portable appliance testing records were not complete as not all rooms had records to prove a test had taken place. There was also no electrical wiring certificate available for inspection. A number of service users rooms were inspected and the service users had kettles in their rooms, the home should undertake where necessary risk assessments to ensure the safety of service users. Wisma Mulia DS0000016654.V277623.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X 2 Wisma Mulia DS0000016654.V277623.R01.S.doc Version 5.1 Page 20 yes Are there any outstanding requirements from the last inspection? 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 OP1 Regulation 6 Requirement The Registered Person must add the following to their Statement of Purpose and Service Users Guide: 1. A time scale of no longer than 28 days to respond with the outcome of a complaint to a complainant. 2. A copy of the homes terms and condition and contract must be added to the Service Users Guide. The Registered Person must ensure that no service users moves into the home without having their needs assessed by a suitably qualified person and a copy of the assessment is in the home. Timescale of the 31/05/05 and this was issued as immediate action at the last inspection dated 8/8/05 was not met. The Registered Person must ensure an assessment of service users needs is undertaken and kept under review. Timescale of the 30/11/05 was not met. DS0000016654.V277623.R01.S.doc Timescale for action 01/05/06 2. OP3 14 01/05/06 3. OP7 14 01/05/06 Wisma Mulia Version 5.1 Page 21 4. OP7 15 5 OP18 13(6) 6 OP30 18(1c)(i) 7. OP29 Sch 2, 7, 9 &19 The Registered Person must ensure that service users care plans are kept under review and maintain records to support this. The Registered Person must ensure staff receive training in the protection of vulnerable adults and to ensure the homes policies and procedures are up to date. The Registered Person must ensure that all staff receive training appropriate to the work they are to perform. This must include fire training. Since the introduction of the POVA scheme, and the amendments to the Care Home Regulations on the 26/7/04 for pre-employment checks on staff, the Home must obtain the following for recruited staff: Proof of identity, including a recent photograph Details of criminal offences of which the person has been convicted, including any details which have been spent; in respect of which he/she has been cautioned by a constable. Criminal Records Bureau disclosure (including a POVA check where applicable). Two written references, including, where applicable a reference relating to the persons last period of employment, which involved work with vulnerable adults, of not less than 3 months duration. Where a person has previously worked in a position which involved contact with children or vulnerable adults, written verification of the reason why the person ceased to work in their last position unless it is not reasonably practicable to obtain DS0000016654.V277623.R01.S.doc 01/05/06 01/06/06 01/06/06 01/04/06 Wisma Mulia Version 5.1 Page 22 8 OP38 23 4(civ) 9 OP38 23 2(b) such verification. Full employment history with satisfactory written explanation of reasons for gaps in employment. Details and evidence of registration with, or membership of, any professional body. Timescale of the 28/2/05 and 31/5/05 was not met. A warning letter has been sent to the home. The Registered Person must 01/04/06 ensure that the emergency lighting is tested as directed by the fire service and maintain records to support this. The Registered Person must 01/04/06 provide evidence that an electrical wiring test has taken place by suitably trained person and portable appliance testing has also taken place on electrical equipment in the home. 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. 2. 3. 4 Refer to Standard OP7 OP33 OP33 OP33 Good Practice Recommendations The home should complete risk assessments for the prevent of falls for all service users. The home should document all monitoring systems undertaken in the home. (This was not followed up at this inspection). The home should collate the results of the service users questionnaires and add these to their Service Users Guide. (This was not followed up at this inspection). The home should send out quality assurance questionnaires on a yearly basis to service users, their relatives/representatives and other stakeholders in the in the community. (This was not followed up at this DS0000016654.V277623.R01.S.doc Version 5.1 Page 23 Wisma Mulia 5. OP38 inspection). The home should undertake risk assessments where necessary for service users who use their kettle in their room/flatlet. Wisma Mulia DS0000016654.V277623.R01.S.doc Version 5.1 Page 24 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.V277623.R01.S.doc Version 5.1 Page 25 - 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!