Inspection on 25/04/06 for Wordsley Hall

This inspection was carried out on 25th April 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

Wordsley Hall 25/06/07

Wordsley Hall 31/10/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Wordsley Hall Wordsley Hall Mill Street Wordsley Stourbridge West Midlands DY8 5SX Lead Inspector Mrs Cathy Moore Unannounced Inspection 25th April 2006 08:00 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 Wordsley Hall DS0000065016.V290641.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. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Wordsley Hall Address Wordsley Hall Mill Street Wordsley Stourbridge West Midlands DY8 5SX 01384 571606 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) Minster Care Management Limited Mrs Mary Costello Care Home 41 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (36) of places Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 5 service users identified in the attachment to the application dated 11 August 2005 may be accommodated at the home in the category MD(E). This will remain until such time that the service users placements are terminated at which point the category will revert back to OP. 7 service users identified in the attachment to the application dated 11 August 2005 may be accommodated at the home in the category DE(E). This will remain until such time that the service users placements are terminated at which point the category will revert back to OP. 1 service user identified in the attachment to the application dated 11 August 2005 may be accommodated at the home in the category MD. This will remain until such time that the service users placement is terminated at which point the category will revert back to OP. 1 service user identified in the attachment to the application dated 11 August 2005 may be accommodated at the home in the category SI(E). This will remain until such time that the service users placement is terminated at which point the category will revert back to OP. No more than 2 two service users to be admitted onto `Peace Unit` per week. 31/10/05 2. 3. 4. 5. Date of last inspection Brief Description of the Service: Wordsley Hall is a large extended property of Georgian origins, which is located near to Wordsley village where there are a range of local amenities examples being; shops, pubs and churches. The public transport system provides easy access to the nearby towns of Stourbridge and Kingswinford. There is ample car parking at the front of the property with level access to the front and rear of the building. There is a garden and patio area to the rear of the home. The home is currently registered to care for 41 people and has 41 single bedrooms, one of which has an en-suite facility. Resident accommodation has two floors accessed by stairs and a passenger lift. The home offers five lounges on the ground floor’ one of which is a designated smoking room and a dining room. It provides a number of assisted and non-assisted bathrooms and toilets in various locations throughout. Since the last inspection part of the home on the first floor has been designated to care for older people who have dementia. It is registered to accommodate five residents’. This section provides 5 single bedrooms, its own living space, toilets and bathrooms. When it is fully occupied it will have its own Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 5 staff team. The new owners who purchased the home in the summer of 2005 continue to be committed and keen to make improvements in all areas of the home and its service delivery. The weekly scale of charges for Wordsley Hall range from £364 to £386. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This main ‘ key’ inspection was carried out by collecting information from the owner and manager. Gathering information regarding events that have happened since the last inspection and undertaking a site assessment inspection of the home. The site unannounced inspection took place over one day between 08.00 and 17.10 hours and involved two inspectors’. Five residents’ were selected for case tracking. This process involved looking closely at each resident in terms what they need, how their care is planned, their daily routines, activities that they are offered, their health, personal and medicine needs, their environment and their relationship with the staff. Medication management and safety were assessed as were the premises health and safety, selected policies and procedures, complaints documentation, meals and menus were also looked at. Seven residents, six staff and two relatives were spoken to during the inspection. The manager, deputy manager and area manger all had some involvement in the inspection. Twenty questionnaires had been sent to the home prior to the inspection for residents’/ relatives to complete to gain their views on the service. Unfortunately, at the time of writing the report only five completed questionnaires had been received. What the service does well: The home belongs to a organisation that owns a number of other homes’, providing a peer and management support network. Senior managers closely monitor the home. It is extremely positive that five of five completed resident questionnaires received confirmed that all had; ’ been given enough information’ about the home in order for individuals to be able to make a decision that the home would be right for them. It is also positive that the homes’ statement of purpose, service user guide and last inspection report are all on display in the homes front entrance all giving valuable information to residents’ and visitors. The homes’ atmosphere is warm, welcoming and positive. Visiting times are open, with no restrictions at all. One resident confirmed that their children or grandchildren visit everyday. Another commented that her; “ Daughters’ visit nearly everyday”. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 7 The residents’ questionnaire has a question which states, ‘Do you like the meals at the home?’. Four completed questionnaires responded as, ‘always’, to this question. One responded as ‘usually’. One resident commented verbally about the food saying, “It is lovely and plenty of it”. It is positive that five of the completed five questionnaires received all confirmed that they knew who to speak to if they were unhappy and that they knew how to make a complaint (if they had the need). Further, one relative spoken to said, “ Mum would tell me if she was not happy about something. I know how to make a complaint if I had to”. Generally, staffing levels for all roles are good. Seven to eight care staff can be on duty morning times. The kitchen has staff on duty everyday between 07.00 and 18.00 hours. The staff continue to be motivated and interested in their work. It is positive that four of the five completed resident questionnaires confirmed that;’ Staff are available when they are needed’. The fifth response to this was ‘usually’. Residents’ spoken to described the staff as; “ Very good, kind and polite”. “All staff are pleasant and are good to us”. ”Only have to ask and the staff help”. One resident said;” All staff are pleasant”. Another said;” The staff are always polite”. 56 of the staff to date have achieved N.V.Q level 2 or above in care. The homes’ structure is old and therefore is never going to be perfect. The premises are however, adequate. There is plenty of indoor and outdoor space. Staff observed during the inspection were respectful to residents’. No ‘pet’ names or inappropriate terms were used. The preferred form of address was determined on admission and recorded on individual personal files. Guidance was seen in care plans in respect of knocking of doors before entering. It was observed during the inspection that toilet and bathroom doors are shut when in use. All bedrooms are now single occupancy increasing resident privacy and dignity. It is positive that a senior manager carries out on a monthly basis visits to the home and produces a report of their findings. A copy of which is forwarded to the Commission. It is also positive that regular resident/relative and staff meetings are held. Records are made of items discussed during these meetings. One relative confirmed; “ I attended the residents’ meeting last week and was able to voice my views”. Two residents’ who had both been in other homes’ commented, ‘That this was the best home they had been in’. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 8 What has improved since the last inspection? What they could do better: Omissions were noted in two residents’ notes in the areas of nutritional screening and risk assessment. Although it is very positive that systems are in place to monitor individual residents’ weights and that these are audited by the manager. Instruction had been given that one resident who had lost weight was to be re-weighed two weekly however, there was no evidence to demonstrate that this was being done. It was identified that the home is not reporting to the Commission as they should when residents’ become ill and require hospital assessment/ in patient treatment. Failure to provide this information leaves a gap in the Commissions monitoring abilities. Risk assessment processes in terms of prevention need to be developed further. It was concerning that one resident was seen leaning out of a first floor window that should have been secured by a window ‘restrictor’. Medications have improved significantly. However, further improvements are needed particularly in terms of guidance for when to give certain medications and how it should be given. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 9 Further work is needed in the area of choice and dignity. Male residents do not have a choice of male or female staff to attend to their personal care as there are no male carers employed. It is unfortunate that the activities Co-ordinator employed only stayed at the home for a few weeks before leaving due to personal reasons. Adequate activity provision is vital in a home of this size who cater for residents’ who have complex needs. More development is needed in the area of adult protection. All staff need to be aware of Dudley MBC protection procedures as these are the ones’ that must be followed. These procedures and a quick reference guide to accompany them are vital. It is important that all staff know of these procedures and where they are kept. It is acknowledged that the new owners have improved the home significantly in terms of the premises, décor and furnishings. A forward thinking refurbishment of fabric and fittings programme is needed to ensure that the home does not deteriorate. The kitchen is in a poor state of repair and requires a full refurbishment. Many bathrooms and toilets particularly on the round floor also require refurbishment. Quality assurance/ monitoring processes and systems need to be developed further. All areas of service provision must be audited at least annually. The views on the service of all stakeholders must be asked. Confirmation of processes regarding the home holding money in safe keeping for residents’ must be sought to ensure that insurance cover is valid and adequate. Short life foods examples being sauces must be date labelled when opened. Plans must be made to ensure that the freezer contents are secure at all times. 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. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 10 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 Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 11 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): 2,3,4. Required systems and documentation relating to the ‘ choice of home’ section which includes; resident contracts/terms and conditions and assessment of need processes are in place and are of a good standard. EVIDENCE: Five resident files were assessed to determine that a contract/terms and conditions document has been issued. Four held the required document, one other was not available as the resident had only shortly before been admitted. Confirmation that contract/ terms and conditions are being issued was gained within the completed resident questionnaires received. Four said that they had been issued with a contract. The fifth commented;” Only been her for 10 days”. The lowest and highest fees are not at the present time detailed in the homes statement of purpose or service user guide as they should be. It is extremely positive that five of five completed resident questionnaires confirmed that all had been given enough information about the home in order for individuals to be able to make a decision that the home would be right for them. One resident and her relative confirmed that ‘they had visited the home Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 12 prior to admission’. It is also positive that the home’s statement of purpose, service user guide and last inspection report are all on display in the home’s front entrance all giving valuable information to residents’ and visitors. Two residents’ who had both been in other homes’ commented; ‘That this was the best home they had been in’. Good documentation was seen on case files examined to confirm that the home has a comprehensive, robust assessment of need process. This process includes the home obtaining required information where applicable from the funding authority to enhance the assessment of need process. A letter to acknowledge to residents’ that their needs can be met by the home was seen and is in operation. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Care planning, health and personal care and medications are adequate all however, require further developments and ‘fine tuning’ to ensure further improvements. EVIDENCE: Five resident files were case tracked. This process included the assessment of care plans, medication administration and health and personal care delivery. This case tracking demonstrated that all residents’ have a care plan which has been produced using the company’s comprehensive format. Care plans seen were linked to assessed needs. It is unfortunate however, that at least two care plans had not been fully completed, potentially leaving these areas of care missed as staff do not have the required instruction. It is positive that one relative confirmed; ”That she had been involved in her mothers care plan”. One of five completed questionnaires received responded to the question; ’Do you receive the care and support you need’ as; “ Usually”. The other four indicated that they always received the care and support needed. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 14 One residents’ daughter said that she was; “ Really appreciative of the care her mother had received recently when she had become unwell”. Residents’ seen were well groomed. Their hair was tidy and they wore appropriate clothing. Omissions were noted in two residents’ notes in the areas of nutritional screening and risk assessment. Although it is very positive that systems are in place to monitor individual residents’ weights and that these are audited by the manager. Instruction had been given that one resident who had lost weight was to be re-weighed two weekly however, there was no evidence to demonstrate that this was being done. It was identified that the home is not reporting to the Commission as they should if residents’ have a serious illness and require hospital assessment/ in patient treatment. Failure to provide this information leaves a gap in the Commissions monitoring abilities. During the inspection one resident was observed trying to climb the stairs. This resident looked very awkward and it was taking a long time. Concern was such that the staff were informed of the situation to prevent injury. The deputy manager confirmed that there was no risk assessment in place relating to this resident and the stairs. There was a weakness in risk assessment process. Risks identified in a number of areas do not have prevention strategies an example of which being; hip protectors in place. One resident commented positively; “ The care is very good whenever I want they will fetch me and take me to the toilet”. Medication systems, administration and storage have improved significantly. The company has provided the home with comprehensive medication procedure and policy, with helpful illustrations of how medication records should be. Staff have a good working knowledge of medication systems and the storage of medication and the medication trolley are well organised. A number of staff at present are undertaking accredited medication training. A number of shortfalls were identified which need action to rectify to prevent risk to residents’. Staff are not at the present time being given clear guidance when ‘ as required’ medications may be administered. The medication fridge temperature was too high. Where medication records are handwritten the information transferred from bottles/packets is not being confirmed by two staff to prevent error. Staff observed during the inspection were respectful to residents’. No ‘pet’ names or inappropriate terms were used. The preferred form of address was determined on admission and recorded on individual personal files. Guidance was seen in care plans in respect of knocking doors before entering rooms. It was observed during the inspection that toilet and bathroom doors are shut when in use. All bedrooms are now single occupancy increasing resident privacy and dignity. One resident said;” All staff are pleasant”. Another said;” The staff are always polite”. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 15 There is a shortfall in that it is not recorded on all residents’ files their choices in being cared for by opposite gender staff. The home at the present time does not have any male carers. Thus giving no choice for male residents’ other than to be cared for by female staff. There was good information on each residents’ file about their spiritual needs, religion and last wishes. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 16 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. Daily life generally and social activities provided by the home are good. EVIDENCE: An activities co-ordinator was recently appointed by the home. Staff and residents’ felt that the activities person was a great asset to the home. Unfortunately, she only stayed a few weeks before leaving due to personal reasons. Activities are provided by the home. A couple of staff have a good reputation regarding activity provision. However, activities can not be provided to the same extent as could be with a designated person. An activities person is essential and would greatly benefit residents’ who have dementia and other conditions where participation is difficult. A comment from a relative confirms this somewhat who said;” Mum does not always wish to participate due to her mental state”. Three of the five completed resident questionnaires said that there were ‘usually’ activities arranged by the home that they could participate in. One made no comment about activities and one agreed fully. Visiting times are open at all times. There are no restrictions during day time hours at all. These visiting arrangements however, are not displayed within the home and are not fully detailed in the homes’ service user guide or statement of purpose. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 17 One resident confirmed that their children or grandchildren visit everyday. Another commented that her; “ Daughters’ visit nearly everyday”. Written materials relating to external advocacy services were seen on display in the entrance hall. Residents’ are encouraged and do bring into the home with them a range of personal processions from clothes to small pictures and ornaments to bigger items. These processions however, are not always fully recorded on their inventory, making tracking difficult if items were mislaid. To date there has been no specific input from the community dietician regarding nutrition and meals for residents’ who are diagnosed as having diabetes. The home has sent menus to the dietician but to date has not received a response. It is positive that the home has large print laminated menus to inform residents’ of the meals provided on any day. Understanding is enhanced further by the use of pictures. Meals provided on the day of the inspection were as follows; Breakfast –cereal, toast and or a cooked option. Lunch- Pork chops or fish cakes, vegetables and mash potato. Followed by fruit and jelly and or ice-cream Tea- Home made soup, ham and cheese flan and baked beans and or assorted sandwiches and bread pudding. Tables were attractively laid. During mealtimes staff were observed giving residents’ choices about food offered. Portion sizes were seen to be adequate. The residents’ questionnaire has a question which states; ‘Do you like the meals at the home’? Four completed questionnaires answered this question as ‘always’, one answered ‘usually’. One resident commented verbally about the food saying;” It is lovely and plenty of it”. Another said;” The food is very nice. The pork chop today was tasty and tender”. Another resident commented happily;” They bring my meals to me on a tray”. Food stocks in the kitchen were seen to be good. All types of foods were available examples being; snacks, cheese, eggs, meat, fresh fruit and vegetables, cereals, bread and sauces. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 18 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 area of complaints and protection, although adequate; requires further development. EVIDENCE: The home has a written complaints procedure. This is detailed in its service user guide and statement of purpose which is positive. No complaints have been received since the new owners purchased the home. The complaints procedure although produced in large print is not produced in a format which may enhance the understanding of all residents’ an example being pictorial. It is positive that five of the completed five resident questionnaires received all confirmed that; they knew who to speak to if they were unhappy and that they knew how to make a complaint (if they had the need). Further, one relative spoken to said, “ Mum would tell me if she was not happy about something. I know how to make a complaint if I had to”. Before the home was purchased by the new owners numerous incidents of abuse between residents’ were occurring almost on a daily basis. The incident of abuse has decreased significantly with only one reported incident in the last three months or so which was reported as it should be to the Commission. This improvement is mainly due to better staffing levels, greater understanding of staff and more appropriate management of residents’ who have challenging needs. The home has its own abuse policies and procedures. The management were unclear which policy belonged to Dudley Local Authority- as this is the one that should be followed if allegations or abuse occurs. There was no evidence Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 19 available to demonstrate that staff have read, signed and dated Dudley MBC’s procedures. There is no quick reference guide to confirm this Dudley’s processes in case an incident occurs which may delay vital reporting. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 20 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): 19,22,24,25,26. The environment, facilities, services and general upkeep of the home is adequate, the main concern in this area being the main kitchen. EVIDENCE: The home is a large, aged detached property. It stands alone in it’s own grounds. The home employs a handyperson. The general maintenance book in which staff record small ‘works’ that need attention is up to date. It is positive that the majority of the work entered in this maintenance book is attended to within two days. The home at the present time does not have a routine, forward thinking maintenance programme. The premises have however, improved significantly since the new owners have purchased the home regarding décor, carpets, furnishings and the safety of the garden. Only two bedrooms are now in need of redecoration, together with the refurbishment of bathrooms and toilets and the replacement of bathroom and toilet floors on ‘ Peace Unit’. The kitchen however, gives cause for concern and is in need of a total refurbishment. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 21 The garden has been ‘fenced ‘ to ensure that residents; who are at risk due to confusion or other do not run from the garden into the road. Thus, allowing them greater freedom of movement as they can now go into the garden on their own. The home has five lounges on the ground floor plus a designated smoke lounge and a dining room. The new ‘ Peace unit’ on the first floor has its own living areas. The home has a number of aids and adaptations examples being; a passenger lift, assisted toilets and bathrooms, grab rails and ramped access. A call system is provided throughout the building. Generally signage is adequate. However, the shower room and one bathroom seen did not have signs. The home has all single occupancy bedrooms. The majority are of a generous size. All but a couple have been redecorated. All have been provided with new floorings. A number of bedrooms lack lockable cabinets. An audit of each bedroom has not been undertaken for all. There was no evidence to demonstrate that the contents of the bedrooms are satisfactory to the residents’. The handyperson has used an appliance to read lux measurements (lighting output) throughout the home. Readings do not appear to be accurate bas they are extremely low and therefore require a re-test. The radiator and hot pipework in one bedroom were seen to be unguarded, posing as a potential risk to the occupant. All hot water outlets are fitted with control valves. Hot water temperatures are taken and recorded monthly. The laundry is equipped with two commercial washing machines and two dryers. It is operated by dedicated laundry staff. It was concerning that the laundry at one point had been left unsupervised with the door left open. A potential risk to residents’ who could have accessed this. The laundry floor was adequate. Sinks were not as clean as they should be. No cleaning schedule could be offered at the time of the inspection. It is positive that ‘hand wash’ signs were on display in toilets and bathrooms. These areas however were not as clean as they should be. Toilet floors on the ground floor were seen to be ‘wet’. It is positive that five of the five completed resident questionnaires stated that; ‘The home if fresh and clean’. No offensive odours were detected during the tour of the premises. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The area of staffing provided at the home is good. EVIDENCE: Evidence was available to confirm that the home has assessed staffing levels /numbers using the prescribed staffing tool approved by the Department of Health. The outcome of this exercise is that the home is providing staff hours in excess of what is required. It is positive that four of the five completed resident questionnaires confirmed that;’ Staff are available when they are needed’. The fifth response to this was ‘usually’. One resident spoken to during the inspection said; “ Sometimes there is enough staff- sometimes there is not- another one would not hurt them. This is usually when someone is off sick”. The home employs seniors, care staff, catering, laundry and cleaning staff seven days per week. Residents’ spoken to described the staff as; “ Very good, kind and polite”. “All staff are pleasant and are good to us”. ”Only have to ask and the staff help”. It is extremely positive that 56 of the care staff team have achieved N.V.Q level 2 or above. Others are working towards this award. It is also extremely positive in that of the four staff files case tracked only one required written reference was lacking. In the past there has been major shortfalls in respect of staff recruitment practices. One other shortfall was identified in that a declaration in respect of one staff members physical health had not been explored as it should have been. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 23 A small number of staff have been employed before their enhanced disclosure had been received. The home had however, received a satisfactory check of the Protection Of Vulnerable Adults list for each staff member and had informed the Commission of their decision to employ these staff. Training has improved since the new owners purchased the home. Evidence was available to confirm that new staff receive in-house induction. Similarly, evidence was available to demonstrate that the home is using the new ‘Skills for Care’- Common Induction Standards. Unfortunately, a staffing matrix was not available to determine the uptake of mandatory training. One staff member commented;” We now have much more support and training”. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. The management and administration provided by this home are adequate. EVIDENCE: The manager has been registered as a ‘fit person’ to run and manage the home by the Commission for some time. The manager ‘ managed’ another home previous to this one. The manager at the present time is undertaking the Registered Managers’ Award. She is also a Registered Nurse. The staff and residents’ have had major change since the new company and manager have taken over. Positive comments are being received about the changes. One staff member said that she felt; “ Supported ”. A quality monitoring system of sorts is available within the home which is linked to a number of written policies and procedures. This system is used to Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 25 audit key areas of service provision. It does not however, at the present time have a framework to audit all areas over a 12 month period. The home has commenced using questionnaires to gain the views and satisfaction or otherwise of residents’, relatives and staff. Questionnaires to gain the formal views of other stakeholders have yet to be produced and circulated. It is interesting that a key-worker system is in place within the home yet at least two residents when asked did not know who their key-worker was. Similarly, a question is asked in the resident questionnaire as follows; ‘ Do the staff listen and act on what you say’? Three of the five returned, completed questionnaires answered; ‘ always’ to this question. One answered;’ Sometimes’. Another; ‘ Usually’. It is positive that a senior manager carries out on a monthly basis visits to the home and produces a report of their findings. A copy of which is forwarded to the Commission. It is also positive that regular resident/relative and staff meetings are held. Records are made of items discussed during these meetings. One relative confirmed; “ I attended the residents’ meeting last week and was able to voice my views”. According to the pre-inspection questionnaire provided by the home. One resident maintains their own benefit book, another handles their own financial affairs. The home does hold at least ten residents’ money in safe keeping for them. This is held in a safe in individual packets. Records are maintained of all money going into the safe and any expenditure. The money and records are audited by the manager. The home has a written policy in respect of handling money. Only two employees have access to the safe. Slight concern was raised in that keys are taken off the premises and that it is not known the upper limit for money held in terms of insurance cover. The money during this inspection was not counted. It is positive that staff have regular, one to one, formal supervision with a senior or manager. Records are held of these sessions and are held on the individual staff members file. Maintenance and service certificates were randomly examined and were found to be in order as follows; the fire alarm system was serviced in April 2006. The outcome of which was recorded as “Everything Fine”. The fire extinguishers were serviced in October 2005. A gas service was carried out in July 2005. A gas landlord’s safety certificate issued in January 2006. The lift was serviced in January 2006. The water system was tested in May 2005. In-house checks are being maintained with records made of for example; the fire alarm system, emergency lighting, hot water temperatures and bedrails. It was observed during the inspection one resident leaning out of a first floor window which may be hazardous. Staff thought that a window restrictor was fitted on the window. Environmental Health carried out an inspection of the homes’ kitchen in March 2006. A number of requirements were made. The kitchen was assessed in Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 26 terms of cleanliness and temperature recording. It is positive that a kitchencleaning schedule is in place and that food; fridge and freezer temperatures are taken and recorded, as they should. One shortfall identified, which could pose as a health risk is that not all sauces and short-life products are being dated and stored correctly once opened. Similarly the freezer is stored in the staff room. The door of this room was not locked, the window open when unattended and their was no lock on the freezer leaving the opportunity for its contents to be tampered with. At least two bedroom doors were seen ‘propped’ open with wedges. This could present as a serious fire risk and fire spread if a fire were to occur. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 27 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 x 2 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 x x 2 x 2 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 3 x 2 Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 28 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 OP1 Regulation 4,5 Requirement The registered persons must ensure that the lowest and highest fee ranges are included in the homes’ statement of purpose and service user guide. The registered persons must expand the existing risk assessment Performa to include prevention measures such as hip protectors and nighttime pressure pads. ( Timescales of 01/05/05, 13/05/05 and 12/12/05 not fully met). This process must also include referral to specialist fall prevention teams. Timescale for action 01/06/06 2 OP8 13(3) 01/06/06 Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 29 3 OP8 12(1) 13(4) The registered persons must ensure that; Nutritional plans are established for service users’ who have poor appetite or any unexplained weight loss. Where plans are put into place for example; weigh every 2 weeks that this is carried out and can be evidenced. 25/05/06 4 OP8 37(1)(d) 5 OP8 13(4) The registered persons’ must ensure that a Regulation 37 notification is made to the CSCI in respect of any ‘ serious illness’ of a resident particularly incidents’ where residents’ have been admitted to hospital. The registered persons’ must ensure that a documented risk assessment is carried out in respect of MB using the stairs with the aim of minimising eradicating any risk. The registered persons must ensure that where possible, any change of medication by a doctor is instructed the doctor is asked to sin the MAR sheet and this is countersigned by staff. ( Reference the homes’ new medication guidance policy example; illustrated guidance for discontinuation of medications. 15/05/06 15/05/06 6 OP9 13(2) 15/05/06 Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 30 7 OP9 13(2) The registered persons must; Give clear guidelines to staff informing them of the circumstances for when’ as required’ medication may be administered. Devise and implement a policy for any medication being taken out of the home for example; trips and outings. (Timescale of 15/11/05 not fully met). 15/05/06 8 OP9 13(2) The registered persons must 15/05/06 ensure that the medication fridge temperature is maintained as satisfactory at all times. If the thermometer is found to be at fault this must be replaced. 9 OP9 13(2) The registered persons must; Ensure that any medication record that is handwritten is confirmed by two staff when transferring the instructions from the medication container to the medication record ( for example; items that are not regularly prescribed – antibiotics ). 15/05/06 Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 31 10 OP9 13(2) The registered persons must; Devise a policy for blood glucose monitoring. A copy of which must be forwarded to the CSCI. 25/05/06 11 OP9 13(2) 12 OP9 13(2) The registered persons’ must ensure that written evidence is forwarded to the CSCI to demonstrate that staff have successfully completed their accredited medication training. The registered persons dispensing pharmacist prints in full any specific administration instructions an example being; those relating to Risedronate administration. 01/06/06 15/05/06 13 OP9 13(2) 14 OP10 12(5) The registered persons’ must ensure that a care plan relating to oxygen administration is on file for those residents who are prescribed oxygen. The registered persons must ensure that preferences and restrictions on choices be negotiated, included in service user plans and be reviewed regularly examples being; to not provide bedroom door keys, personal care given by opposite gender staff, the opening of service user mail. ( Timescales of 01/04/05, 13/07/05 and 01/12/05 not fully met) 15/05/06 25/05/06 Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 32 15 OP12 12(1)(a) 16(2)(m) The registered persons must expand existing activities to provide stimulation for service users’ with dementia which includes recognised therapeutic interventions, reminiscence therapy, cognitive therapy and stimulated presence therapy. ( Timescales of 01/04/05, 01/08/05 and 01/01/06 not fully met). 01/06/06 16 OP12 16(2)(m) (n) 18(1)(a) 12(4)(b) The registered persons’ must appoint a suitably, qualified activities person. 25/06/06 17 OP12 18 OP13 4,5 19 OP14 17(2) Schedule 4 (9)(10) The registered persons’ must 25/05/06 ensure that large, easy to read clocks are available in living areas to enhance orientation. The registered persons must 01/06/06 ensure that visiting times are fully reflected in the homes’ statement of purpose and service user guide and that they are displayed within the home in a format appropriate to the residents’. The registered persons’ must 25/05/06 ensure that a full inventory is completed for each resident on admission ( this to include all personal items examples being TV, Furniture etc). This inventory must be signed by staff member, resident ( or chosen other) and be maintained at all times. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 33 20 OP15 16(2)(i) 17(2) The registered persons must; Establish a specialised menu for diabetics in liaison with the community dietician. Undertake a documented liaison with the community dietician regarding the current menu plan to ensure that it meets the nutritional needs of the service user group particularly to calcium and vitamin D. ( Timescales of 01/04/05, 13/07/05 and 20/12/05 not fully met). The home has forwarded menus to the dietician and is awaiting a response. The registered persons must ensure that the complaints procedure is produced in a format appropriate to the needs of the residents’ example being; pictorial. ( Timescales of 13/07/05 and 01/01/06 not met). 01/06/06 21 OP16 22(2) 01/06/06 22 OP18 13(6) The registered persons must develop strategies for ensuring that staff remain, familiar and understand the principles of vulnerable adult abuse policies. ( Timescales of 13/07/05 and 15/11/05 not fully met). 01/06/06 Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 34 23 OP18 13(6) 24 OP18 13(6) The registered persons’ must 15/05/06 ensure that written risk assessments and protocols are in operation so that staff and contractors on site are perfectly clear what areas of the home these contractors can access and what they can and can not do within the building/ contacts with residents’ etc. The registered providers’ must 25/05/06 ensure that all staff are fully aware and conversant with Dudley MBC adult protection procedures. They must read, sign and date the procedures. A flow chart must be produced as a quick reference document giving contact names and telephone numbers for staff to reference if needed. 01/06/06 The registered persons must provide appropriate signage, symbols, colours and furnishings throughout the home to assist service users’ with dementia in orientation. ( Timescales of 01/04/05 and 01/08/05 not fully met). One bathroom and shower room noted during the tour of the premises. 25 OP19 23(2)(n) Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 35 27 OP19 23(2)(b) The registered persons must fit suitable pass locks to all bathrooms and toilets. (Timescales of 01/04/05,01/08/05 and 01/01/06 nearly met). There are still two outstanding. . 01/06/06 28 OP19 23(2)(b) 23(2)(d) 29 30 OP19 OP19 16(2)(l) 23(2)(b) 23(2)(b) The registered persons must produce an on-going forward thinking refurbishment of décor, fabric programme complete with timescales. ( This to include timescales for the refurbishment of ground floor toilets and bathrooms. The replacement of flooring in toilets/ bathrooms Peace Unit. The redecoration of bedrooms that have not been redecorated to date. The registered persons must fully refurbish the main kitchen. The registered persons must provide the CSCI with a written guarantee stating that the windows throughout the home are in safe, good working order. 01/07/06 01/09/06 01/06/06 31 OP21 23(2)(b) The registered persons must consider providing floor to ceiling doors/ partitioning in all toilets. (Timescale of 01/02/06 not met). 01/07/06 Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 36 32 OP24 23(2)(e)1 6(2)(l) The registered persons must ensure that a lockable cupboard is provided in all bedrooms. (Timescales of 01/08/05 and 01/01/06 not fully met). At least 5 bedrooms randomly viewed did not have a lockable facility including rooms;6,12,16 and 23. 01/06/06 33 OP24 16(20(i)2 3(2)(e) The registered persons must ensure that restrictions on residents’ choices are negotiated and documented in service user plans and reviewed regularly; the non- provision of certain items of furniture as required by standard 24.2 and bedroom door keys. ( Timescales of 01/04/05, 01/08/05 and 01/01/06 not fully met). This must include asking/ ensuring that light switches and electrical sockets are at heights suitable for each resident. 01/06/06 34 OP25 23(2)(p) The registered persons must ensure that the lighting in each room is of LUX 150 standard. 01/06/06 Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 37 35 OP25 13(4) 36 OP26 13(3) The registered persons must ensure that all radiators and hot pipe work throughout the home are suitably guarded. An example being bedroom 36. In the interim period risk assessments must be in place to prevent burning. The registered persons must ensure that mop heads are laundered daily at disinfectant temperatures. ( Timescales of 01/01/05, 13/07/05 and15/11/05 not fully met). No documentary evidence to demonstrate that this is being done. 01/06/06 15/05/06 37 OP26 13(3) The registered persons’ must ensure that; Cleaning schedules are in place for all areas within the home including the laundry ( particularly the sinks), toilets and bathrooms. Staff must sign and date these after tasks have been completed. 15/05/06 Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 38 38 OP29 19(4) The registered persons must ensure that a staff file including all documents as detailed in Schedules 2 and 4 of the Care Home Regulations 2001 for each staff member is available on site at all times. ( Timescale of 31/10/06 not fully met). Only one written reference was not on file for one staff member CD). The registered persons’ must ensure that all staff is physically fit to work at the care home. Documentary evidence of this must be obtained from the doctor of the staff member highlighted during the inspection. A written risk assessment in respect of this person must also be carried out and held on this persons file. The registered persons must; Implement an effective quality assurance system. Ensure that ‘self monitoring’ of the homes performance continues. Ensure that the results of any resident/ relative/other stakeholder survey are published. ( Timescales of 01/08/05 and 01/01/06 not fully met). 15/05/06 39 OP29 19(5)( c) 01/06/06 40 OP33 24(1)(2) (3) 01/07/06 Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 39 41 OP35 16(2)(l) The registered persons, must; Find out from their insurance company what the upper limit for safe contents is. Gain their insurance companies view about the safe keys being taken off the premises. 25/05/06 42 OP38 13(4) 18 (1)(a) The registered persons must ensure that all staff have valid certificates or receive the following training ; First aid; Food hygiene; Moving and handling; Hoist usage. 01/07/06 43 OP38 13(4) 44 OP38 13(4) 45 OP38 13(4) The registered persons must 01/06/06 ensure that the freezer stored in the staff room is replaced with one that has a lock facility. Or the existing freezer be fitted with a suitable lock. The registered persons must 10/05/06 ensure that the laundry door is locked at all times when it is not in use. The registered persons must 10/05/06 ensure that all windows ( at least above ground floor level) are fitted with a suitable restrictor and that these are in working order at all times. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 40 46 OP38 13(4) 23(4) The registered persons must ensure that suitable door closing mechanisms linked to the fire alarm system are fitted to all residents’ doors – who want their doors held open example being FP). For advice on this matter contact West Midlands Fire Service. The registered persons’ must ensure; That all jams, sauces and short life foods are date labelled when opened. That any food taken out of their original packaging in the fridge or freezer are labelled with the original use by/ best before dates. 25/05/06 47 OP38 13(4) 16(2)(j) 15/05/06 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 Refer to Standard OP9 OP29 Good Practice Recommendations The registered persons’ should ensure that a ‘ patient information leaflet’ is obtained for all medications presently being prescribed. The registered persons should actively try to recruit a number of male staff. Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 41 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Wordsley Hall DS0000065016.V290641.R01.S.doc Version 5.1 Page 42 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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