Inspection on 08/08/05 for Wisma Mulia

This inspection was carried out on 8th August 2005.

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 24/02/06

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 Gloucestershire GL2 7HE Lead Inspector Sharon Hayward-Wright Unannounced 8 August 2005 10:30 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 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 D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Wisma Mulia Address Bridge Road Frampton-on-Severn Gloucestershire GL2 7HE 01452 740432 01452 740084 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Fountain Housing Association Limited To be considered for registration Care Home 25 Category(ies) of Old age (25) registration, with number of places Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 18/1/05 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 D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4 hours on one day in August 2005. Seven service users were spoken with to gain their views on the home and the care of four service users was looked at in detail. Four staff members and the Manager were also spoken with. Staff were observed going about their duties and interacting with each other and service users. The requirements issued at the last inspection were followed up and records relating to care, duty rotas, personnel files of new staff and staff supervision records were inspected. Since the last inspection the home has a new Manager in post and staff and service users spoke very highly about him. The Manager demonstrated an awareness of the areas that need improvement, however he has only been at the home a short while and will need more time to complete this task. Six requirements remain outstanding since the last inspection and now must be addressed. What the service does well: The meals in the home are good offering both choice and variety and catering for special dietary needs. The service users either have their own flatlet or large room in the main house that are in excess of the recommended spacial requirement mentioned in the National Minimum Standards for Older People. The staff demonstrated good understanding of the service users needs and service users felt they have built good relationships with the staff. Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 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 standard(s) 1, 3 & 5 Improvements must be made to the admission procedure to ensure that there is a proper assessment prior to people moving into the service. Without this there is no assurance that care needs will be met. Service users’ and their relatives are able to visit the home prior to moving in. EVIDENCE: At the last inspection the home was issued with two requirements to send copies of the completed Statement of Purpose and Service Users Guide to the Commission for Social Care Inspection. To date this has not been addressed and the requirements remain outstanding. The new Manager said both guides were completed and available in the home. Three new service users’ have been admitted to the home since the last inspection, however none had pre admission assessments completed. The home must complete pre admission assessments to ensure they can meet their assessed needs. One service user that came from hospital had hospital discharge information in their care file. Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 Page 9 Two of the new service users spoken with confirmed they had knowledge of the home prior to moving in and one had visited the home. Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 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 standard(s) 7, 8 &10 There is no clear or consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. The health needs of service users are met and the staff treat the service users with respect and maintain their privacy. EVIDENCE: Four service users were case tracked but one service user was out and therefore was not spoken to about their care. None of the care plans had an assessment of the service users needs therefore this would make it difficult for staff to identify any care needs and plan the care needed. This must be addressed. The service user receiving respite care did not have any care plans despite using a walking aid and needing assistance to get into the homes ‘Parker Bath’. The service user also said the staff were helping them to gain confidence on using the stairs. One service user now requires more assistance from staff, however this was not reflected it their care plans; they did have care plans for their daily activity but again this did not reflect the service users’ current condition. Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 Page 11 Another new service user does not require any assistance from the staff, however a risk assessment must be completed as this service user goes out alone using a motorised ‘buggy’. Evidence was seen of ongoing reviews of care plans but the staff are not updating the care plans. Detailed daily records are maintained as well as a list of health professional visits. Staff spoken with had a good understanding of the care needs for the service users. Moving and handling assessments are in some service users care plans but not all, these must be completed for all service users to ensure risks to their health are minimised. It is recommended that risk assessments for the prevention of falls be completed on all service users. Evidence of service users being weighed was seen in some care plans. Health professionals are accessed for service users with an assessed need. Medication was not inspected in full, however the staff said the home now has a trolley to assist in the administration of medication and that the staff use the MAR sheets in this process. For safety the staff must use the lockable facility to transport the medication to service users on the first floor in the main house. Service users’ spoken with confirmed that the staff maintain their privacy and dignity by knocking on their door prior to entering and they receive their post unopened. Service users said they are able to chose how they are addressed by the staff, e.g. by their first name or surname. Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 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 standard(s) 12 ,13 & 14 Social activities are organised on a planned basis, however the home needs to ensure the social needs of all service users are met. Links with the local community and service users’ family and friends are encouraged and maintained. The meals in the home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: From discussions with service users’ and the Manager, activities are provided on a planned basis to include weekly and fortnightly. Two service users said they are bored at times. The Manager is going to review activities. The home is in the process of building a studio where service users can paint or undertake other activities. The home has a car driver who is able to take service users’ out on a social basis and to appointments on a planned basis. Many service users’ lead an independent and active life and can come and go as they please. Links with the community are maintained as service users can go to the local village. Visiting is flexible and accommodation is available for service users relatives/friends. Relatives and friends are able to stay for meals and several were staying for lunch on the day of the inspection. Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 Page 13 Service users’ where able can exercise choice and control over their lives and lead an independent life. Service users’ personal possessions where seen in their flatlets. Service users’ spoken with all praised the food provided by the home saying it is delicious and choice is provided. One service user said they chose to eat certain food and the home is providing this for them. One of the two requirements issued at the last inspection in relation to health and safety checks has been addressed; the other one remains outstanding and had been issued again at this inspection. Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 Page 14 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 standard(s) No standards were assessed at this inspection. EVIDENCE: Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 Page 15 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 standard(s) No standards were assessed at this inspection. EVIDENCE: Service users said they are happy with the cleanliness of their flatlets and the home in general. Staff were observed wearing protective clothing as needed. Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 The staff demonstrated a good understanding of the needs of the service users and service users said good relationships had been formed between them and the staff. Since the last inspection the standard of vetting and recruitment practices has improved, but not all the required checks are being completed and this could potentially leave service users at risk. EVIDENCE: The Manager, staff and duty rotas confirmed the staffing levels on each shift. The staff expressed concerns about the care of one service user and that they are covering additional shifts at times due to annual leave. The staffing for an early shift is three care staff, two on a late shift and at night. The staff said they communicate with each other through pagers due to the layout of the home. A recommendation is that ‘walkie talkies’ may be of use to the staff. Due to the layout of the home and the increased care needs of one service user, the home must review its staffing with a view to increasing the levels to ensure no service users are put at risk. Service users’ all praised the staff in the home saying they are very friendly and helpful, but always busy. Service users’ felt they had good relationships with the staff. Since the last inspection two new members of staff have started work. Their personnel files were inspected. Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 Page 17 The first file only had one written reference and a reference from the last employer was sent to a ‘team leader’ and not the actual employer. Reasons of why this person left their last post were not requested, as they should have been, as they had come from a care position. The second file had two written references but one was not on headed notepaper and it would be difficult to ascertain where this came from. It was difficult to find a full employment history on the application form used for this person. A requirement was issued at the last inspection for the home to ensure they meet the Care Homes Regulations when they appoint new staff; not all of this has been addressed and must be, to ensure the no service users’ are put at unnecessary risk. Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 & 36 The service users and staff feel the new Manager provides them with leadership, guidance and they feel he is fit to be in charge of the home. The Manager demonstrated an awareness of the areas that need improving and he is working towards addressing these. EVIDENCE: Since the last inspection a new Manager has started at the home and has sent his application to the Commission for Social Care Inspection to be considered for registration. He has experience of running a home and is a qualified Social Worker. Staff and service users spoke very highly of the new Manager saying he is friendly and approachable. Two service users’ said “they had prayed some one like him would come to the home and he has”. Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 Page 19 The Manager demonstrated an awareness of where changes and improvements are needed, however he has only been at the home for a short time. A requirement issued at the last inspection for the home to send copies of Regulation 26 visits has not been complied with and has been issued again at this inspection. The Manager has started staff supervision and maintains records of the sessions, however as he has only been in post a short time he had not had time to supervise all staff as yet. He has plans to address this. Photographs of recently admitted service users are required as listed in Schedule 3 of the Care Homes Regulations. Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 1 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 2 3 2 x x 2 2 x Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 Page 21 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 1 Regulation 6 Requirement The Registered Person must send a copy of their revised Statement of Purpose to the Commission. Timescale of the 1/4/05 was not met. The Registered Person must send a copy of their revised Service Users Guide to the Commission. Timescale of the 1/4/05 was not met. The Registered Person must ensure that no service users moves into the home without having their needs assessed by a suitabley qualified person and a copy of the assessment is in the home. The Registered Person must ensure an assessment of service users needs is undertaken and kept under review. The Registered Person must ensure that service users care plans are individualised and reflect the service users current needs. The Registered Person must ensure that risk assessments for moving and handling needs are D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Timescale for action 1/11/05 2. 1 6 1/11/05 3. 3 14 immediate and ongoing 4. 7 14 30/11/05 and ongoing 30/11/05 and ongoing 30/11/05 and ongoing Page 22 5. 7 15 6. 7 15 Wisma Mulia Version 1.20 7. 9 8. 15 9. 27 10. 29 completed for all service users and that these are reviewed on a frequent basis to ensure their needs are being met. Timescale of the 28/2/05 was not met for the frequent reviews of the risk assessments. 13(2) The Registered Person must ensure that the lockabe facility is used to tranport the medication around the first floor in the main house for safety . 13(4c) The Registered Person must ensure that temperatures are taken of food deliveries ie frozen and chilled meat and records maintained to ensure any unecessary risks to service users health are minimised. Timescale of the 31/1/05 was not met. 18 The Registered Person must review the staffing levels to ensure they meet the changing needs of the service user discussed and the layout of the building. Schedule Since the introduction of the 2, POVA scheme, and the Regulation amendments to the Care Home s 7, 9 and Regulations on the 26/7/04 for 19 pre-employment checks on staff, the Home must obtain the following for future recruited staff: Two written references, including, where applicable a reference relating to the person’s 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 D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc immediate and ongoing immediate and ongoing immediate and ongoing immediate and ongoing. Wisma Mulia Version 1.20 Page 23 11. 33 26 12. 37 17 & Schedule 3 their last position unless it is not reasonably practicable to obtain such verification. Full employment history with satisfactory written explanation of reasons for gaps in employment. Timescale of the 28/2/05 was not met. The Registered Person must 31/8/05 send copies of the report from their unannounced monthly visits as required in this Regulation. Timescale of the 28/2/05 was not met. The Registered Person must 31/8/05 obtain photographs of the recently admitted service users. 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. 5. 6. Refer to Standard 7 7 27 33 33 33 Good Practice Recommendations The home should complete risk assessments for the prevent of falls for all service users. The home should review care plans and risk assessments on a monthly basis. The home should review the communication aids used by staff to ensure they can communicate with each other at all times. 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 community. (This was not followed up at this inspection). Wisma Mulia D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection 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 D51_D03_16654_Wisma Mulia_v221384_310505_stage 4.doc Version 1.20 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!