Inspection on 25/06/07 for Wordsley Hall

This inspection was carried out on 25th June 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 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 25/04/06

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 June 2007 07:15 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.V342295.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 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.V342295.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wordsley Hall Address Wordsley Hall Mill Street Wordsley Stourbridge West Midlands DY8 5SX 01384 571606 01384 572226 wordsleyhallcare@btconnect.com 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 (7), Old age, registration, with number not falling within any other category (34) of places Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 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 MD 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. One named service user under the age of 65 years. 11th December 2006 ( random) 25th April 2006 ( key) 2. 3. 4. 5. 6. 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. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 5 The first floor has been designated to care for older people who have dementia. It is registered to accommodate seven service users’. This section provides single bedrooms, its own living space, toilets and bathrooms. 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 £353 to £410. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced key inspection on one day between the hours of 07.15 and 17.30 hours. Part of the inspection was carried out in lounge areas so that I could observe daily routines, meals and staff and service user involvement. Before the inspection questionnaires were sent for service users’ to complete to give me an idea about their views on the service provided by the home. Ten questionnaires were returned. During the inspection I was fortunate to speak with three staff, five service users’ and five relatives. They were happy to share with me their experiences and observations made about the home. I looked at four service users’ files to assess admissions processes and care planning. I looked at four staff files to assess recruitment processes, supervision and training regularity. I looked at medication systems to assess safety and health and safety records to make sure that equipment and appliances are being properly serviced. I looked at parts of the premises to include four bedrooms, three lounges, two dining rooms, the kitchen, bathrooms, three toilets and the laundry. The manager was involved in the inspection process as was a senior manager from the home’s organisation. What the service does well: I spoke with a number of service users’ and their families all, only made positive and complimentary remarks about the home examples being; “ I am really impressed. It is spotlessly clean”. “ Lovely, run as a place should be”. “ Very good, very nice”. “ Very good. Better than the last place. Did not like that at all”. “ Nice place. I was so worried, but it’s really good”. “ Very good I am really happy here”. “ The home is nice”. “ I’ve been here for 14 years. Very good, no complaints”. One service user told me; “ I’d recommend it to anyone”. The home belongs to an organisation that owns a number of other homes’ providing a peer and management support network. Senior managers continually monitor the home. The home employs a full time administrator to keep records up to date and to prevent the manager having to undertake admin tasks. The organisation and home should be congratulated on the improvements made since they purchased it in the summer of 2005. At that time the home had well over 110 requirements, which have now all been addressed. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 7 The manager is suitably qualified and experienced. She is registered with the Commission as a fit person to be in charge of the home. The home’s atmosphere continues to be warm, welcoming and positive. Staff are kind and caring, pleasant and friendly. I could see that they have a good relationship with the people in their care. The home has open visiting times. Service users’ are very much encouraged to maintain contact with family and friends. Well over the required 50 of the care staff team have achieved NVQ level 2 or above. What has improved since the last inspection? What they could do better: The home has been given very few requirements or recommendations this reflects the considerable improvements made in all areas. Medication systems need some ‘ very fine’ tuning to increase safety further. Staff absence must be covered for example; when staff are on holiday or sick leave. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 8 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. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 9 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.V342295.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4. Quality in this outcome area is good. Information is provided to prospective service users’ in a written and part pictorial format to help them decide weather or not the home will be suitable for them. No service user is admitted to the home unless their needs have been assessed and that they have been assured that these can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: I saw a lot of different written materials in the home examples being; the service user guide and visiting times. Which, is good as it gives prospective service users’ and their families information to help them decide if the home will be suitable for them or not. That the home provides enough information to prospective families was confirmed by completed service user questionnaires received. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 11 Ten out of ten said that they had received enough information about the home before they moved in so that they could decide if it would be right for them. I saw that the homes’ service user guide has been reviewed since the last inspection. It has been produced in part writing and part pictorial form to increase understanding. I saw a written assessment of need on all files that I looked at. One relative told me; “ The manager came to see her when she was in the last place”. The manager provided me with a letter to confirm that the home assures new service users that their needs will be met. This evidence is positive as it demonstrates that the home does not admit any person unless their needs have been assessed and can be met. I did have a discussion with the senior manager about admitting additional people who have a diagnosis of dementia. She told me we would not admit any service user unless we are sure that their needs can be met. It was decided that further discussion will take place in the future about this. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. Service users’ health and personal needs are set out in an individual plan of care. Service users’ health care needs are fully met. Medication systems need some’ fine tuning’ but are generally safe and robust. Service users’ are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: I looked at four service users’ care plans. One needed to be updated as changes had occurred during the previous weekend. The manager told me that this was to be done on the day of the inspection. I identified that one service user did not ever sleep in her bed but in a recliner chair, however this was not reflected in her care plan. Other than these issues care plans I saw were fairly detailed and comprehensive reflecting the needs of each service user. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 13 I spent a number of hours observing in the dementia unit. Staff I observed spent time with the service users’. They sat and talked to them and encouraged them to talk back. One service user started to sing and the others joined in. This was clearly enjoyed by all. All service users’ I observed looked well cared for and were dressed appropriately. One relative told me; “ They really care for her”. Another told me; “ She always looks nice. They try to match her clothes”. A service user told me; “ Oh yes, the staff really look after you”. I looked at health care records and saw that health care services are accessed regularly. Records for one service user confirmed that she had been seen by the doctor on 3.11.06, 19.6.07 and had a medication review on 26.2.07. The home was not happy with this service users condition on the 20.6.07 so called the doctor again who, admitted her to hospital. She had also been seen by the nurse on 25.10.06 to have the flu injection and the optician on the 8.12.06 and 21.12.06 when she had two new pairs of glasses. The dentist on 21.3.07 also saw her. Another service users records confirmed that staff had observed her body for bruises when she was admitted and that she was being weighed every month. I saw records to confirm that another service user was being weighed weekly because of concerns about weight loss. Staff told me; “ Healthcare, that’s alright get the doctor or ambulance”. “ Oh yes, well cared for and safe. No delays in getting medical treatment”. “ All services. The doctor has been in today”. Relatives told me; “ The doctor is very good. Two pairs of glasses recently and a hospital visit”. A service user told me; “ Yes they look after me. I see the doctor and chiropodist”. This evidence clearly shows that the health and personal care needs of service users’ are being met. I observed the staff member administering medications on the dementia unit. I observed good practice as she ensured that drinks were available before she started giving the medications. Each time she left the medication trolley I saw that she made sure that it was locked and she stayed with each service user to make sure that they had taken their medication. I looked at medication systems and saw that a photograph of each service user is near to their medication record to ensure correct identification. That an example staff initial list was available so that tracking of persons giving medication could be carried out. I saw that medications and controlled drugs were stored appropriately and that there were no staff initial gaps on medication records indicating that medication is being given, as it should. I saw that there was clear instructions to staff for medications that have to be administered in a certain way an example being; Alendronic Acid. The staff member showing me the medication systems had a good of knowledge about medications and the systems in the home. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 14 I did identify some shortfalls for example; medication boxes for Temazepam and Adcal had not been date labelled when opened which may prevent effective audits taking place. The pharmacist had not recorded allergies or none allergies on the top of medication records. A number of hand written medication records had not been verified by two staff to confirm that the information had been transferred correctly. Generally though medication systems are well managed which increases the well- being and safety of service users’. I saw that the preferred form of address had been identified for each service user and recorded on their file. I observed service user and staff involvements. Staff, were polite to service users’ giving them choices wherever possible. I saw that bathroom and toilet doors were kept shut when in use to ensure privacy and dignity. One relative told me; “ They speak ever so nice to her”. One service user confirmed that staff encourage independence she told me; “ I look after myself. Staff, just help me in and out of the bath. I change my own bed”. These practices demonstrate that the privacy, dignity and independence needs of service users’ are addressed by the home. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. Service users’ find that the lifestyle experienced by the home matches their expectations and preferences. Visitors’ are welcomed at any time. Service users’ are encouraged to maintain contact with family and friends. Meals offered are varied and nutritious. This judgement has been made using available evidence including a visit to this service. EVIDENCE: I went to the dementia unit at about seven thirty in the morning. Out of seven service users’ only two were up, washed and dressed. I asked the two service users’ if they liked getting up at that early. One told me she did, the other did not understand my question. A staff member told me;” No one else wants to get up this morning”. I heard another carer saying to the two service users’ who were up; “ Everyone else is snoring at the moment, no-one wants to get up”. Later I saw that other service users’ got up at various times during the morning. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 16 I saw that a record is made of the preferred rising and retiring times of each service user. I spoke to other staff and service users’ about rising times and was told; “ I get up and go to bed when I want to”. “ They get up when they want and go to bed when they want”. This evidence is positive as it shows that daily routines are arranged to suit the preferences of service users’ not the home. The home is fortunate in that an activity co-ordinator has been appointed. She works five days a week Monday to Friday. I was told; “ Things have improved. We have an activities lady. They can go out and do things in the home”. “ A lady comes, we do bingo and cards. The vicar also comes to the home. Sometimes they take me out in the wheelchair”. During the afternoon I saw that activities were being carried out in the ground floor lounge, which service users’ enjoyed. During the time I spent on the dementia unit I was impressed by the staff’s involvement with the service users’. I saw that they sat with the service users’ and encouraged them to talk and also encouraged service users’ to talk to each other. I saw that one staff member had a game of dominoes with one service user. Visiting times are open and flexible. During the inspection I saw a number of visitors’ coming and going. Service users’ told me about their families and the visits they have. Records of visits are maintained. I looked at one service users’ file and saw that she went out very often with her family; 3.6.07 gone out to daughters. 5.6.07 daughter visited. 16.6.07 out for lunch. Two relatives I spoke to told me that they visited the home every day and were made to feel welcome. One said; If I am here at lunch time they give me a meal as well”. The other said; They make me feel welcome, very friendly”. Information about external advocacy services is available for the service users’ to access if they want to. All bedrooms I looked at held a range of personal belongings making them feel personalised and homely. Information to the Local Council is updated to ensure that service users’ can vote if they want to. The home has recently introduced a new menu. I saw that food on the menu was interesting and varied. The cook told me; “ We have introduced this new summer menu to give more choice at tea time which offers more salads and things like jacket potatoes. I highlighted to the manager that supper should be added to the menu to ensure that service users’ all know that supper is offered. During the time I spent in the lounge I saw that drinks were offered to service users’ frequently. Jugs of squash were also available in the lounges at all times. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 17 I partly observed the breakfasts on the dementia lounge. A range of cereals and toast were offered. One man chose egg, tomato and toast. I partly observed the lunch served in the rear lounge where three men had their meal on tables provided in there. Lunch was fagots or toad in the hole served with potatoes and vegetables, followed by bread and butter pudding or jelly. I saw that one male service had a soft diet and a plate guard to assist him to eat more independently. The meals looked and smelt nice. The male service users’ all told me that they had enjoyed their food. Everyone made positive comments about the food as follows; “ Really lovely, we can chose”. “ Meals very good and plentiful. Choice of menu everyday”. “ Sometimes too much!”. I spoke to one relative she told me; “ I come everyday to feed Mum her lunch. I like to do this and they let me. The way the meal comes is beautiful. Although she has a soft diet it is all-individual on the plate. They give her plenty of drinks as well”. The manager told me that she has secured input from the dietician. Who will be putting a service into the home where needed. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. Complaint processes in the home meet the required Regulations. The complaints’ procedure has been produced in a part pictorial format to aid understanding. Procedures are in place for the protection of vulnerable adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission about this home received two complaints. These were given to the provider to investigate. There was no evidence to uphold these. I saw that the home has a complaints book to record any complaints received and action taken. The home has a complaints procedure on display within the home. It is also included in the service user guide. The home has a part pictorial and part written procedure to aid understanding. We had ten completed service user questionnaires. About complaints the following was determined. Five of ten service users’ confirmed that they know who to speak to if they are not happy, five answered usually to this question. Eight of ten confirmed that they know how to make a complaint, one said that they did not and one did not answer. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 19 During the inspection relatives told me; “ I’d speak to Mary, she is very approachable”. “ Go to the office, oh yes I’d be happy to do that”. This evidence shows that the home has complaints processes in place and most people know how to access these if they need to. There have been no allegations received since the last inspection concerning this home. If incidents do occur between service users’ the home now a good track record of reporting these to the relevant agencies. The home has in place processes to safeguard service users’ From records viewed I determined that the majority of staff have received protection training. Staff I spoke to all confirmed that they have received this training. I asked staff, service users’ and visitors’ if they had ever seen anything concerning in the home such as swearing; shouting, rough handling or hitting. Their responses were as follows; “ Oh, no, never. They are golden to Mum. They talk to her ever so nice”. “ No, never seen anything like that”. “ No, never”. “ Not since I’ve been here”. “ No, nothing like that at all”. This evidence demonstrates that service users’ are safeguarded in the home. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,26. Quality in this outcome area is good. Service users’ live in an environment, which is fairly well maintained that is comfortable and homely. The home offers generous sized living space. With a number of different rooms to meet needs and give choice. The home is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection a new handyperson has been employed who attends to the maintenance needs of the home. The home continues to improve in respect of the premises. I saw that the home was bright and clean. A staff member who confirmed this observation; “ Great deal of improvement since Minster took over, decoration and furniture”. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 21 The home offers a number of different lounges, which allow service users’ to make choices about where they spend their time. One relative told me; “ This lounge much better than the last home she was in. More activity and things going on”. I looked at four bedrooms and found these to be adequately decorated, well furnished, comfortable and clean. One relative told me; “ Her room is so lovely”. I spent time on the dementia lounge and found this to be pleasant and bright. Pictures on the walls, flower displays and lamps making it feel very homely. I was interested to see the ‘ bus stop’ area that has been made for service users’ to go and sit. The home has generous sized gardens, which are fenced off for privacy and safety. I was told that a number of service users’ enjoy going in the garden in the nice weather. I looked at bathrooms and toilets to assess infection control processes within the home. I was pleased to see that these areas were clean and equipped with items to promote infection control such as liquid soap and paper towels, gloves and aprons. Hand wash signs were lacking in some bathrooms and toilets but this was addressed before the inspection finished. I told the manager that the toilet room on the first floor with the red door needs to be provided with a bin for the service users’ to put their used paper towels in. The laundry is small for the size of the home. I saw however, that it was fairly well organised and I could see that attempts have been made to keep clean and dirty washing separate to prevent contamination. The laundry is equipped with commercial machines, which have sluice wash cycles for adequate cleaning of even soiled items. I did not detect any odour in the home. One relative told me; “ Spotlessly clean. No smells, always fresh”. About the cleanliness of the home I gained the following from completed service user questionnaires; Seven of ten confirmed that the home is always fresh and clean, two said usually and one did not answer. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. Generally adequate staffing numbers meets service user needs however, better contingency planning is needed to cover sickness and holidays. NVQ attainment at the home is very good and gives assurance that staff have been assessed as competent to carry out their work. Recruitment processes generally are robust and safe. Induction processes are in place to equip new staff with the required knowledge to do their jobs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During day time hours six care staff are provided and four at night. In addition the manager is on site during business hours and cooks, cleaners and laundry staff are provided every day. Everyone I spoke to told me that these staffing levels are adequate but problems do occur when people go off sick or are on holiday. The following is what I was told; “ Enough staff”. “ Staffing levels ‘ in between’”. “ Sometimes short due to sickness”. “ Enough staff except when people phone in sick”. “ Hard work when short staffed. Sometimes short sickness and holidays”. To ensure that adequate staffing levels are provided at all times to make sure that service users’ are safe contingency arrangements must be made to cover sickness and holidays. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 23 The home has a high staff attainment level regarding NVQ awards. All but two of the whole care staff team either have or are working towards this qualification. I saw written evidence to confirm that induction processes are in place for new staff to equip them with the required knowledge before they commence work. I looked at four files and was pleased to see that recruitment processes are in place to protect service users’ from the risk of harm. I saw for example; that each staff member had completed an application form, had provided official identity and had been checked by the Criminal Records Bureau. In general adequate references had been obtained for all. However, I did note that one had not been obtained from a previous training provider for one staff member as should have been. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. Quality in this outcome area is good. The Commission has approved the manager as a fit person to run and manage the home. Quality monitoring processes along with methods to involve service users’ and relatives mean that the home is run in the best interests of the service users’. Service user money is held securely and records are maintained to ensure safety. Staff are supported by regular one to one supervision from seniors and management. Some ‘fine tuning’ is needed regarding health and safety to protect service users’ from having accidents. This judgement has been made using available evidence including a visit to this service. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 25 EVIDENCE: The Commission as a fit person to be in charge of the home has approved the manager. She is a Registered Nurse and has just completed her Registered Managers Award. The manager since her appointment has led the home from it’s previous state, which was very concerning to its present, very much improved state about which service users’ and relatives had only good things to say. Relatives and staff alike told me that they found the manager approachable as follows; “ Yes, work along well with Mary”. “ Anything I go to Mary”. The home has in place a system to monitor it’s own performance. Audits are carried out on areas such as medication to keep them safe. The home holds meetings for staff and service users’ for them to be kept informed and give their views. Regular questionnaires are used to gain the views of service users’, staff and relatives about the services provided. I checked four service user monies held in safekeeping. I found that these were correct against balances and totals. Receipts are kept to evidence expenditure. Whilst I was in the office one, service user came and asked for some money showing that she knew who to approach to access her money. I looked at staff files and saw written evidence to confirm that they receive regular one to one supervision. Staff themselves confirmed this. All that I spoke to told me that they have regular supervision and meetings are held regularly. Environmental Health carried out an inspection of the home’s kitchen in February 2007. Two minor issues were raised which have since been addressed. Since the last inspection the kitchen has been refurbished. Old tiles have been removed from the walls. The walls have been painted and new flooring provided. New stainless steel racks in the pantry have replaced the old wooden shelving. The kitchen feels like a new room. I saw that was in good order, clean and bright. I looked at the cooks’ diary books and saw that these are being completed every day as they should be, to include cooked food and fridge and freezer temperatures. I looked at a range of service certificates to ensure that appliances and equipment are being checked, as they should be to ensure safety within the home. Certificates I saw confirmed that they are as follows; Fire alarm service 4.5.07, electrical portable appliance testing Jan 07 and hot water temperature checks 13.6.07. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 26 Two issues need to be addressed to prevent accidents within the home. I saw exposed hot pipe work in one bedroom. I saw from records that two service users’ have had falls I did not see however, that their risk assessments had been reviewed following these falls to prevent re-occurrence and risk. Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 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 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 3 x 2 Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 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 OP9 Regulation 13(2) Requirement Medication records that are handwritten must be confirmed by two staff when transferring the instructions from the medication container to the medication record to prevent errors. Timescale of 15.5.07 not fully met. This requirement has been made to increase medication safety. 2 OP9 13(2) All medication packets must be date labelled when first used to ensure an effective audit. Medication totals must be transferred over onto new medication records where applicable. This requirement has been made to increase medication safety. 27/07/07 Timescale for action 27/07/07 Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 29 3 OP9 13(2) The pharmacist should be asked to print on the top of MAR sheets allergies or none known. This requirement has been made to protect service users and to keep them safe. 27/07/07 4 OP29 19(4) Where staff have been employed by a previous care provider or other then one of their references must be obtained from this provider. Staff absence ( holidays and sickness) must be covered at all times. This requirement has been made to ensure that service user needs are met and that they are safe. 27/07/07 5 OP27 18(1)(a0 27/07/07 6 OP38 13(4) The registered persons must ensure that all hot pipe work throughout the home suitably guarded. An example being bedroom 36. Risk assessments should be reviewed for VW and OW. This requirement has been made to prevent accidents and keep these service users’ safe. 27/07/07 7 OP38 13(4)( c) 27/07/07 Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 30 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 OP4 OP14 Good Practice Recommendations Plans regarding the admission of future service users; should be discussed with the Commission. The registered persons’ must 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. The registered persons must consider providing floor to ceiling doors/ partitioning in all toilets. The full names should be listed of all staff attending fire drills to fully evidence attendance. 3 4 OP21 OP38 Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Halesowen Local Office West Point Mucklow Office Park Mucklow Hill Halesowen B62 8DA 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 Wordsley Hall DS0000065016.V342295.R01.S.doc Version 5.2 Page 32 - 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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