Inspection on 27/09/05 for Wisteria House

This inspection was carried out on 27th September 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

Wisteria House 26/07/07

Wisteria House 19/07/06

Wisteria House 08/12/05

Wisteria House 09/02/05

Wisteria House 14/06/04

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 Wisteria House Montacute Road Tintinhull Yeovil Somerset BA22 8QD Lead Inspector John Hurley Unannounced Inspection 27th September 2005 10:00 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 Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 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. Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wisteria House Address Montacute Road Tintinhull Yeovil Somerset BA22 8QD 01935 822086 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) Mrs Siobhan Cecilia Wortley Mr Stephen John Wortley Mrs Siobhan Cecilia Wortley Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2005 Brief Description of the Service: Wisteria House is a two-storey Hamstone building situated in the centre of the village of Tintinhull, local amenities are nearby. The home has been registered as a service for older people since 1985. Wisteria House is registered to provide care and accommodation for thirteen people. Due to the physical environment, Wisteria House is best suited to meet the needs of those with low to medium dependency. All rooms are for single occupancy. Mr and Mrs Wortley, have been the registered providers since March 2004. Mrs Wortley is also the registered manager. Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over five hours on an unannounced basis. Most of the staff was at the home to attend a training session, the inspector spoke with five of them on an informal basis. The inspector viewed all areas of the home and met with some service users individually and as a group. The inspector spoke with the care manager who was in operational control of the home along with their deputy. A number of records were examined including a sample of service users care plans, risk assessments, staff records and health and safety records. The care manager has recently returned from maternity leave. The care manager informed the inspector that a significant number of issues relating to the homes operation have fallen below the National Minimum Standards. These mainly related to documentation such as care plans and review. An announced inspection is planned for December to ensure that standards have improved. What the service does well: 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. Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 6 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 Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 7 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): 1,2,3,6 The statutory requirements to keep key documents within the care home are not being met. EVIDENCE: There was no initial assessment documentation available at the time of the inspection, similarly the statement of purpose and service users guide was not available. Contractual information was unable to be inspected. The care manager who had recently returned from maternity leave explained to the inspector that these documents were at the registered managers home. The care manager informed the inspector that intermediate care was not a feature of the home. Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 8 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): 7,8,10 All service users care plans need to clearly set out what the plan of care is. These plans must be reviewed on a monthly basis and further detail any health care interventions made. EVIDENCE: The inspector sampled a number of the records that were available for inspection relating to care planning. The standard of these documents varied. The registered manager informed the inspector that since returning from maternity leave they had began to address the requirements to review care plans and ensure that the home was continuing to meet the service users needs. The documents that have been reviewed demonstrated what the needs were and how they should be met. They further demonstrated that the service user had been consulted with regards to their plan. The service users who the inspector spoke with confirmed that they felt that their needs were being met, staff the inspector spoke with appeared knowledgeable with regards to the individuals needs. However until such time as all of the care planning documentation have been reviewed it is hard to ensure that a consistent approach is being taken. Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 9 The individual service users confirmed to the inspector that local doctor and district nurse team regularly visit when required. It would be helpful if the documentation evidenced when these visits occurred and for what reason. Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 10 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 Service users appear comfortable with their daily routines. The food appears to meet the nutritional needs of the individuals and is served in homely surroundings. EVIDENCE: Some of the service users informed the inspector that the home now has a member of staff who is responsible for activities and entertainment. One individual explained that they have gone out to the pub recently. Another informed the inspector that they had regular sessions of bingo. The records viewed further indicate that there are exercise sessions. Although on closer inspection of the records the activities book showed long period when no activities took place. The service users confirmed that they have visitors when they wish and that they come and go pretty much as they please. Service users also expressed their satisfaction with their surroundings and informed the inspector that they felt safe at the home. All service users the inspector spoke with said that the staff help them when they want help. One individual commented, “ wherever you are you will never get everything perfect, but this will do for me”. Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 11 The inspector briefly observed the lunchtime meal. The tables were well laid out and the staff made every effort to ensure not only the ambience was good but also that the service user had a degree of choice. One service user told the inspector that the staff no what I like and how much I like. The inspector noted that there was plenty of fresh fruit available to the service users at anytime of the day. Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 12 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): These set of standards were not accessed on this occasion. EVIDENCE: Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 13 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): 19,20,23,24,25,26 In general terms the home replicates a normal domestic dwelling with service users being enabled to personalise their own rooms. The home is generally clean and pleasant but in order to ensure the safety of the service users and staff more must be done with regards to fire safety and safe practices with regards to heating arrangements. The management need to consider how using the kitchen as an entrance to the building impacts on hygiene issues in this area. EVIDENCE: The inspector toured the premises with the registered manager. Most of the bedrooms that were viewed had been personalised by the occupant. The service users expressed satisfaction with not only their individual rooms but also the communal space. The home was found to have retained many of its domestic type features. During the tour of the building it was noted that the environment was clean with no unpleasant odours Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 14 The main front entrance is not easily accessible. The inspector observed that it appeared to be standard practice that staff and service users used the entrance that leads straight into the kitchen, as this is accessible. The care manager agreed that this was generally the case but visitors had been stopped from using the kitchen route. This may undermine food handling and safety requirements; the management need to consider the impact of this practice. During the tour of the building it was noted that in three rooms there was electric fan heaters on the floor. The care manager explained that the heating to these rooms had been problematic. There were no risk assessments available with regards to these potential dangerous heaters. Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 15 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): 29,30 The staff continue to have opportunities to train and develop their own personal practice. Shortfalls with regards to industry standard training such as first aid, infection control and manual handling are being addressed. Whilst there is some missing information with regards to the staff files the management have demonstrated that they have identified the problems and are taking action to ensure compliance with the standards. EVIDENCE: At the time of the unannounced inspection a manual handling training session was due to take place. It was noted that night care staff had come in to attend the training. The records that were inspected demonstrated that the management had undertaken training needs analysis and were taking steps to address the shortfalls that had been identified. Several of the staff are undertaking National Vocational Qualification course at differing levels. The staff the inspector spoke with was able to inform them of the needs of the service users and how they meet them. At the time of the inspection the management were in the process of ensuring that the staff records contain all the information required to meet the National Minimum Standards required. Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 16 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): For a period of time the home has not been effectively managed and many standards have fallen below what is expectable. Fire doors must be serviceable and carry out the function for which they are intended. EVIDENCE: The homes management prior to the unannounced inspection has identified a number of issues that impact on their ability to meet the minimum standards. Key records and documents were either not available for inspection, incomplete or out dated. The care manager informed the inspector that this was due to a previous senior member of staff failing to keep up to date. The laundry area that had been of concern has now been refitted and now meets the standard required. Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 17 The requirement relating to fire doors made at the last inspection had yet to be attended too, that being that all designated fire doors either be kept closed or that fire guards to keep them open be installed and well maintained. Wedges must not be used in fire doors. An immediate requirement was made at the time of the inspection instructing the registered person to attend to this matter. Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 18 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 1 1 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 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 x 17 x 18 x 2 3 x x 3 3 2 3 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x x x x 2 Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(2)(b) Requirement The registered person must update care plans to reflect current goals and outcomes and clearly record the dates of service users care plan reviews . The registered manager must ensure that all records required by regulation are available for inspection at all times The registered manager must complete risk assessments on the enviroment and working practices and record the findings of these assessments. They must take action to minimise any risks found. The registered manager must ensure care practices treat the service users with dignity and respect at all times. It is required that all designated fire doors either be kept closed or that fire guards to keep them open be installed and well maintained. Wedges must not be used in fire doors. Timescale for action 01/11/05 2 OP3OP2OP 1 OP38 17(1ab)(2)(3ab)(4) 13 4(a)(c) 05/10/05 3 01/11/05 4 OP10 12 (5) (a)(b)(4) (a) 13(4)(c) 27/09/05 5 OP38 27/09/05 Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Wisteria House DS0000058877.V260504.R01.S.doc Version 5.0 Page 22 - 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. 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