Inspection on 06/03/07 for Wisteria Lodge

This inspection was carried out on 6th March 2007.

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

The inspector 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

Wisteria Lodge 25/03/08

Similar services:

Thorndene

Sutton Lodge Nursing Home

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Wisteria Lodge Horney Common Nutley Nr Uckfield East Sussex TN22 3EA Lead Inspector Jennie Williams Key Unannounced Inspection 6th March 2007 10:50 Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 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 Lodge DS0000067935.V330413.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 Adults 18-65. 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 Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wisteria Lodge Address Horney Common Nutley Nr Uckfield East Sussex TN22 3EA 01825 714080 01825 714081 wisterialodge@sussexhealthcare.org www.sussexhealthcare.org Sussex Health Care 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) Mr Rezaul Hossen Care Home 10 Category(ies) of Learning disability (10), Physical disability (10) registration, with number of places Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is ten (10). Service users must be aged between eighteen (18) years and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated Service users may also have a physical disability. Date of last inspection New Registration Brief Description of the Service: Wisteria Lodge is a care home registered for ten (10) places for service users, of either gender, aged between eighteen (18) and sixty-five (65) years of age on admission, who have a learning and physical disability. The home is registered to provide nursing care. The home is located in Forest Row off the main A22 road. It is owned by Sussex Healthcare who owns numerous care homes throughout the South of England. Wisteria Lodge is located on the same site as another care home owned by Sussex Healthcare. These services are run independently from each other and both have their own communal facilities. The home is purpose built and has wheelchair access throughout. All rooms are for single occupancy and are located on ground floor. Staff accommodation is provided on the first floor. All rooms are provided with a toilet and shower en suite facilities. Overhead tracking hoists are located in some areas of the home to assist in the manual handling of service users. There is a good-sized lounge room, dining area and a sensory room located within the home. There is an accessible garden area located off the dining area, which is used solely for the service users of Wisteria Lodge. In addition to en suite facilities there is; one wet room with shower and toilet facilities, an assisted bath and a large spa bath for service users to use. There is a staff room and two toilets for staff and three visitor toilets. Weekly fees range between £1400 and £2000. There are additional fees; hairdressing (£6), chiropody (£12.50), Holidays and outings (varies). This information was provided to the CSCI on the 22 February 2007. Prospective service users find out about the home through social service referrals and word of mouth. Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over seven hours on the 6 March 2007. Five service users were present throughout the inspection and four service users returned to the home at the end of the inspection. All service users were spoken with. Due to the disability of some of the service users, the Inspector had limited communication contact with them. Ten service users surveys were sent to the home of which three were returned. All had been completed with assistance from a family member. One care plan was looked at in detail and specific areas of care were viewed in a further four care plans. The Registered Manager and five staff were spoken with during the inspection process. Three staff files were viewed. Ten relative/visitor comment cards were sent to the home of which eight were returned. A pre-inspection questionnaire was received after the inspection. A tour of the environment was provided and some individual rooms were viewed. Fire records and medication procedures were inspected. The quality assurance system was discussed and complaint records were viewed. Copies of the staff rota and menus were viewed. Service users monies were checked. Apart from fire records, no other health and safety records were viewed as this information has been provided in the pre-inspection questionnaire. There were nine service users residing at the home on the day of the inspection. One service user was currently staying with family. What the service does well: There is a good pre admission process that ensures only service users whose needs can be met at the home are admitted. Prospective service users are provided with an opportunity to ‘test drive’ the home. Care plans provide clear guidance to staff on how to meet the assessed needs of service users. Service users inare provided with choice and independence encouraged wherever possible and within an individual,s ability. Limited risk taking can be initiated due to the complex needs of the service users. Service users are provided with opportunities for personal development and to be involved in the local community. Visitors are welcomed at the home. Menus in place ensure service users are provided with a healthy diet and any specialist needs are catered for. Service users receive personal support in the way they prefer and require and there is specialist equipment provided to assist in this process. Health needs are being met with the good support network within Sussex Healthcare and with external health professionals. Medication procedures in place ensure that service users and staff are safeguarded. Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 6 Complaints are dealt with appropriately, reassuring those involved that they are being listened to and that action will be taken, if necessary. Service users are safeguarded by the Safeguarding Adults procedures in place and the training provided to staff. There are clear procedures in place for the safe handling of service users monies. Service users live in a clean and homely environment and are provided with excellent indoor and outdoor communal facilities. Service users’ needs are currently being met with the number and skill mix of staff on duty and are safeguarded by the recruitment procedures in place. Staff receive training appropriate to their roles. Staff and service users benefit from a well-run and managed service. The quality assurance and quality monitoring system being developed will ensure that the home is run in the best interest of service users. The health, safety and welfare of service users and staff are promoted and protected so far as is reasonably practicable. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre admission process ensures that only service users whose needs can be met at the home are admitted. Prospective service users are provided with an opportunity to ‘test drive’ the home. Intermediate care is not provided. EVIDENCE: The Statement of Purpose and Service Users Guide were assessed during the registration process. The Registered Manager confirmed to the Inspector that these documents are also available in a format suitable to the service users. These documents were not viewed at this visit. All prospective service users are assessed prior to admission. Head office of the organisation undertook the pre admission assessment for nine of the service users. The Registered Manager confirmed that all prospective admissions are discussed with him prior to an individual moving in. The pre admission assessment viewed demonstrated that the home undertakes a thorough assessment prior to anyone being admitted. A pre admission assessment could not be located for one service user on the day, however the Registered Manager confirmed that head office of the organisation had Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 9 completed one. Copies of other health professional assessments are obtained wherever possible. All prospective service users are encouraged to visit the home at least three times prior to moving in. Overnight trial visits are also provided if needed. Relatives or someone who knows the individual’s needs and preferences are invited to stay overnight on the first night of admission. This is to educate and show the staff how an individual receives personal care, in the way they are used to and prefer. The Registered Manager confirmed that there was no one residing at the home from any minor ethnic community, social/cultural or religious groups with any specific needs or preferences. The home does not have dedicated accommodation to provide intermediate care, however respite care is available if there is a spare place available. Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are being met by the information contained in the care plans. Service users are provided with choice wherever possible. Due to the profound disabilities of the service users, limited risk taking can be initiated. EVIDENCE: Care plans viewed provided information to the care staff on how to meet the assessed needs of the individual. These are written in the first person and read to be personalised to the individual and have pictorial information throughout, as well as written information. There are specific folders for certain aspects of care being provided that is kept individually from the care plan. Some information regarding all individuals was being recorded on the one page. The Registered Manager was made aware that this may cause complications if someone is wishing to access records pertaining to them. Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 11 The registered nurses currently review care plans on a monthly basis. This involves input from the key workers. It was confirmed that representatives are contacted if the needs of an individual changes. Staff spoken with confirmed that they found the care plans to be service user orientated and user friendly. The Registered Manager confirmed that all nurses are being booked onto a course on Person Centred Care Planning. One individuals record observed demonstrated that the service user had not received a bath/shower for three days. The Registered Manager confirmed that this was not the case; staff had not completed the daily care records. He has previously addressed this shortfall in staff meetings. This has not been reflected as a requirement as the Registered Manager is taking action to address this and will be able to ascertain who was working on the days involved and address this shortfall with the individuals involved. Staff encourage and support service users to make their own decisions about their lives and maintain independence within the individuals abilities, wherever possible. There were clear procedures in place for staff to ascertain the views and wishes of one service user through the use of pictures. It was observed on the day of the inspection that staff are familiar with service users’ subtle ways of communicating. The Registered Manager confirmed that service users meetings are held every two months where likes/dislikes, future plans and activities are discussed. Service users are provided choice wherever possible. Due to the profound disabilities for some service users, staff also liase with family members/representative to assist in ascertaining an individual’s preference. There are risk assessments in place for specific activities that may pose a risk for an individual. These provide guidance for staff on action to take to reduce these risks. The home has been proactive and is aware that an individual likes opening and shutting doors. Protective guards have been placed on all door hinges to avoid any risk of fingers being jammed. All information pertaining to service users is kept confidentially. Care plans are kept near the reception area; however there are staff present within the home to ensure information is only read by those requiring this information. Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with opportunities for personal development and to be involved in the local community. Visitors are welcomed at the home. Relationships are supported and encouraged. Service users are offered and provided with healthy diets. EVIDENCE: Service users are encouraged and supported to continue their own personal developments. Independence is promoted wherever applicable. This was observed at lunchtime, where service users were encouraged to be independent. Some service users have been provided with motorised wheel chairs to ensure they continue to be independent and able move freely around the home. There is a small kitchen on site and service users participate is some cooking activities with the activity co-ordinator. Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 13 Two service users attend a day centre twice a week, whilst all other service users attend once a week. One service user is supported to go to college three times a week. There was no service user currently involved in any employment. Service users are supported to be part of the community. All service users participate in an outreach programme two to three times per week. This includes visiting parks; pubs, cinema and enjoying live music performances. Two staff spoken with confirmed that they felt service users get ‘plenty of outings’. The Registered Manager confirmed that he has contacted a local church to see what can be arranged for service users who may wish to fulfil their religious needs. There is an activities co-ordinator and assistant employed at the home five days a week. Staff are currently providing activities for service users in the temporary absence of the activities person. Five service users were observed to be making mother day cards on the day of the inspection. The Registered Manager confirmed that holidays have already been planned and booked for the service users. Service users’ lifestyle is their own choice, however there are routines in place due to service users having to attend sessions outside of the home environment. These routines are flexible, but due to the needs of the individuals’, service users respond better when there is a familiar routine in place. Visitors are welcomed at the home. There is a visitor’s book located at the entrance of the home that all visitors must sign when entering and leaving the home. The Registered Manager confirmed that staff routinely contact an individual’s representative once a week to keep them updated on an individuals life and health matters. Some written comments received were: ‘… is well cared for. Everyone is so happy. Staff are wonderful, caring and all times make you part of the family’ and ‘So far all of the staff at Wisteria Lodge have been very welcoming, caring, professional and eager to help in every situation’. The Inspector enjoyed lunch with the five service users remaining at home. Lunchtime was observed to be relaxed and unhurried. Service users independence is encouraged wherever possible. This was evident with specialist equipment being purchased to keep meals warm for those who are able to feed themselves whilst taking their own time. All service users are able to eat orally. There is a feeding regime in place, which staff are trained, to feed an individual via their specialist feeding tubes. Snacks are provided on site. Food for Wisteria Lodge is prepared and cooked at the other home located at the same site. Menus are specifically implemented for the service users at Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 14 Wisteria Lodge. There had been a complaint made regarding the provision of food for one individual. A menu has been implemented specifically for this individual to ensure all their likes and dislikes are catered for. Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and require. Health needs are being met with the good support network within Sussex Healthcare and with external health professionals. Service users are safeguarded with the procedures in place for dealing with medications. EVIDENCE: It was observed throughout the inspection that personal support and nursing care is provided by staff, whilst ensuring the individual’s privacy and dignity are respected. Service users independence is encouraged and maximised wherever possible. As previously explained, the admission procedures ensures there are procedures in place to ensure staff are familiar with the preferences about how individuals and moved, supported and transferred. There is a key worker system in place that assists in the continuity of care for the service users. Each service user has a named nurse. There is a physiotherapist that works full time at the home and ensures service users have the technical aids and equipment they need for maximum Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 16 independence. Some service users have standing aids, however these can only be used under the supervision of the physiotherapist until staff have received training on the correct use of this equipment. Service users’ health care needs are monitored and advice is sought from the relevant specialist when needed. The pre-inspection questionnaire demonstrates that a GP visits the home twice a week. A dietician visits the home every three months or earlier if there are any identified problems. There is an Occupational Therapist employed by Sussex Healthcare who is available to the home when needed. A chiropodist visits the home every six weeks. Other hearing/sight or Community Psychiatric Nurse (CPN) input is accessed via a referral through the GP. Registered Nurses administer medicines and are responsible for the ordering and recording of medications. Medication Administration Records (MAR) charts viewed demonstrated that medication is being signed for at the time of administration. Service users photos are on the MAR charts to reduce the risk of errors being made. The Registered Manager confirmed that he undertakes audits to ensure that correct medication procedures are being followed. Oxygen was being stored in the medication room, however there was no warning sign advising this. The Registered Manager rang the supplying company whilst the Inspector was at the home requesting that appropriate signage be provided. This has not been reflected as a requirement as the Registered Manager was taking action to address this shortfall. It is recommended that the nurse making changes sign any handwritten amendments on MAR charts. Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with appropriately, reassuring those involved that they are being listened to and that action will be taken, if necessary. Safeguarding Adults procedure ensures service users are protected. There are clear procedures in place for the safe handling of service users monies. EVIDENCE: The Registered Manager confirmed that there is a complaints procedure available and is also available in a format suitable for the service users. There have been no complaints raised directly with the CSCI. There have been five complaints made directly to the home. Records viewed demonstrated that peoples concerns are listened to, investigated in a non-biased way and necessary action taken if identified. Copies of correspondence relating to complaints are maintained. There have been no Safeguarding Adult alerts made since the registration of the service. Staff spoken with confirmed that they are familiar with the procedures to follow in the event of an allegation of abuse being made. It was identified in the CSCI registration report that the Registered Manager demonstrated an in-depth knowledge in many areas including Adult Protection policies and procedures. The home is not an appointee for any service user. All current service users have their parents managing their savings. The head office of the organisation Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 18 uses an imprest system. A minimal float is held on site. Receipts are obtained for any financial transactions. A receipt is given to a visitor anytime they may leave money for an individual. This money is then forwarded to head office to be placed into the individuals imprest account. Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users live in a clean and homely environment and are provided with excellent indoor and outdoor communal facilities. EVIDENCE: Wisteria Lodge is located on the same site as another care home owned by Sussex Healthcare. These homes are run independently from each other and are provided with their own communal facilities. The home is newly purpose built and suitable for its stated purpose. A brief tour of the environment was provided. Rooms were seen to be personalised to reflect the individual’s character and personality. The Registered Manager confirmed that service users were involved in choosing the colour for their room. Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 20 A thorough inspection of the environment was not undertaken on this occasion, as it is a newly built home and was assessed during the registration process. Staff spoken with were complimentary about the environment and one commented to the Inspector that it was good that ‘there were no radiators present as the heating is built into the floor’. There is overhead hoist tracking provided in all bedroom and bathrooms, as well as the sensory room. This ensures that there is limited manual handling required for staff and service users are handled the least amount of times. The home was clean and free from offensive odours on the day of the inspection. All relative/visitor comment cards demonstrated that the home was kept clean. There are sluice facilities provided at the home. One written comment received was ‘very impressed with the cleanliness and friendly staff’. The pre-inspection questionnaire demonstrates that there are policies and procedures in place for disposal of clinical waste, control of substances hazardous to health, communicable disease and infection control. The content of these were not met. Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are currently being met with the number and skill mix of staff on duty and are safeguarded by the recruitment procedures in place. Staff receive training appropriate to their roles. EVIDENCE: The pre-inspection questionnaire demonstrates that there are five registered nurses employed and eight care staff, of which six have achieved their National Vocation Qualification level 2 or above. Staff observed on the day of the inspection demonstrated they had the knowledge and experience in looking after the service users at the home. Two of the visitor/relative comment cards received felt that in their opinion that there are not always sufficient numbers of staff on duty. All staff spoken with confirmed that they felt there were sufficient staff on duty at all times. There is a registered nurse on duty at all times. There is a rota in place identifying which staff member is to provide specific care for an individual receiving one to one funding. There have been no staff leaving since the Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 22 opening of the home and agency staff have not been required to be used. This consistent team of staff ensure that continuity of care is provided. The Registered Manager confirmed that there is generally four care staff and a registered nurse during daytime hours and one carer and registered nurse that work a waking night. The Registered Manager confirmed that head office of the organisation undertakes the recruitment checks on all new staff. Staff files viewed identified that all recruitment checks are undertaken for all staff. References are obtained, along with an application form and an enhanced Criminal Record Bureau (CRB) undertaken for all staff. The Registered Manager confirmed that Protection of Vulnerable Adults (POVA) First checks had been undertaken for staff required to commence employment prior to an enhanced CRB being returned. Clear information on the dates of these checks should be maintained at the home. Evidence of current registration with the Nursing and Midwifery Council (NMC) is obtained for all registered nurses. Staff spoken with confirmed that they are provided with mandatory training and are provided with enough training opportunities. A registered nurse confirmed that nurses are provided with suitable training relevant to their roles. Certificates of training participated in were seen to be kept within the individual staff file. The pre-inspection questionnaire demonstrates that there is a variety of training planned for the future including: epilepsy, wound care, gastrostomy feeding and rectal diazepam etc. Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff and service users benefit from a well-run service. The quality assurance and quality monitoring system being developed will ensure that the home is run in the best interest of service users. The health, safety and welfare of service users and staff are promoted and protected so far as is reasonably practicable. EVIDENCE: The Registered Manager was registered with the CSCI during the registration process of the new service. He is a registered nurse with current registration with the Nursing and Midwifery Council (NMC). He confirmed that he will be commencing the Registered Manager Award course at the end of the month. The Registered Manager confirmed that he has been receiving regular Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 24 supervision from a senior person within Sussex Healthcare as part of the conditions of his registration. Staff spoken with all confirmed that they find the Registered Manager to be supportive and approachable. The quality assurance process was discussed with the Registered Manager. Due to service being newly registered, limited quality monitoring has been undertaken. Surveys are proposed to be undertaken initially every two months for service users and representatives. Head office of the organisation receives feedback and will send the home a copy of the results. It was discussed with the Registered Manager that when developing a quality monitoring process, that feedback is sought from visiting health professionals and other stakeholders. It was also recommended that an analysis of these results be made available to service users and other interested parties. The head office of the organisation develops policies and procedures. None of these were viewed. The registration report demonstrates that there are comprehensive policies and procedures in place and have been personalised to Wisteria Lodge. There is suitable equipment provided throughout the home to ensure safe practices are maintained in relation to manual handling. All relevant health and safety certificates were provided to the CSCI during the registration process to demonstrate that the new build complies with all relevant building regulations and legislation. Fire alarms are tested weekly and the Registered Manager confirmed that fire drills will be undertaken twice a year. The last fire drill was in January 2007, which was confirmed by the staff spoken with. No other health and safety records were viewed as suitable information was provided in the pre-inspection questionnaire. Wisteria Lodge DS0000067935.V330413.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 Adults 18-65 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 X 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 4 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 26 N/A 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. Standard Regulation Requirement Timescale for action 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 YA20 Good Practice Recommendations That the person making the changes signs any handwritten amendments made to the MAR chart. Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone Kent..ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wisteria Lodge DS0000067935.V330413.R01.S.doc Version 5.2 Page 28 - 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!