Inspection on 31/10/05 for Wordsley Hall

This inspection was carried out on 31st October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wordsley Hall 25/06/07

Wordsley Hall 25/04/06

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Inspirations

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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/ Mrs Jean Edwards Unannounced Inspection 31st October 2005 08:15 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.V260904.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 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 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 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. 8 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. 13/06/05 2. 3. 4. 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 43 people and has 41 single and 1 double bedroom. One bedroom has an en-suite facility. Resident accommodation has two floors accessed by stairs and a passenger lift. The home has a total of three lounges and one dining room. It provides a number of assisted and bathrooms in various locations throughout. Since the last inspection the home has changed ownership. The new owners are committed and keen to making improvements in all areas of the home and its functioning. Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two inspectors on one day between 08.15 and 16.15 hours. The inspection was carried out as the second of the homes two routine inspections for this year. The inspection looked at areas that were not assessed during the last inspection and outstanding requirements made following previous inspections. To this end resident files were examined to include assessment of need documentation, care plans, healthcare visits, risk assessments and daily records. Staff files were also examined focusing on recruitment and selection, training and other required documentation. Other records examined included those relating to health and safety and residents’ finances. Medication systems were also looked at. A total of seven residents’ and four staff were spoken to. These conversations took place to gain their views on the services and standard of care provided. The premises were partially assessed which included a number of bedrooms, toilets, bathrooms, the lounges, dining room and garden. The new manager, the deputy and senior managers from the new organisation were involved in the inspection process. Not all standards were assessed during this inspection for a full overview of services provided/ standards of care this report must be read together with the last inspection report dated 13 June 2005. What the service does well: The home since the last inspection has been sold and taken over by a new organisation. This organisation has at least 13 other homes and can offer ongoing support and guidance. The new organisation demonstrate a commitment to improve the home to the required standards. This has been demonstrated already by the meeting of a significant number of past requirements made by the Commission for Social Care Inspection. It is positive that the new organisation have already and intend to continue to invest into the home to ensure that care is delivered properly and any required refurbishment work is undertaken. This has been evidenced by work already Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 6 carried out, the increase of staffing levels, redecoration of a number of rooms and the provision of fencing and gates in the rear garden. Management of the new organisation are quick to respond when problems arise, they are helpful and friendly. It was positive to see that a number of residents’ felt comfortable to enter the office and speak to the manager. All of whom knew the managers name. The staff team are generally motivated, although a number have found it difficult to adjust to changes that have occurred. What has improved since the last inspection? The home as previously mentioned has been taken over by a new organisation who are investing in the home in terms of refurbishment and mechanisms in order for it to improve. Care staffing levels have improved since the last inspection. New posts, examples being; a care manager to assist the registered manager, a handyperson and housekeeper have been created and appointed into. The new organisation have started to implement systems examples being; care plans, policies and procedures to improve working practices. A set of digital weighing scales for more precise monitoring of residents’ weights has been purchased. Residents’ weights are now being monitored at least on a monthly basis. It is pleasing that the home now are able to evidence in detail daily personal care delivery to each resident. Although medication systems have improved somewhat there is a long way to go before they can be deemed as safe. The premises have much improved. The garden has been made safer by the provision of robust fencing and gates. The lounges and dining room have been re-decorated, have been provided with new floor coverings, new lighting and curtains. Some new furniture examples being; dining chairs and a television cabinet have been purchased, other new furniture has been ordered. One resident said about the dining room;” it is lovely now, much better”. A number of bedrooms have been re-decorated and new carpets have been provided. New bed linen has also been purchased and has been put into use. The homes new management have confirmed that the refurbishment programme is to continue until all the required work has been completed. Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 7 A training analysis has been carried out to determine training needs. The majority of staff have or are about to receive abuse awareness training. Fire training for all staff has been arranged for week commencing 31 October 2005. One staff member commented;” This organisation is much more professional. Staff now have to follow policies and procedures. Things are a lot better”. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 8 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.V260904.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Considerable work has been carried out to produce a new statement of purpose and service user guide. These documents must be finalised and be put into operation. Terms and conditions documents have not been issued to all residents’. Residents’ and their relatives know that when they enter the home their needs will be met. Prospective residents’ and their families have the opportunity to visit and assess the quality and services provided by the home. EVIDENCE: It is positive that a draft of both the statement of purpose and service user guide were available within the home. The management confirmed that these would soon be finalised and put into operation. A terms and conditions document was available within the home. Unfortunately, there was no evidence to demonstrate that the newest resident had been issued with one of these documents. Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 10 There was ample evidence to demonstrate that the newest residents’ needs had been assessed prior to her admission. This was carried out by a representative of the home at the hospital where she was an in- patient prior to her admission. The assessment of need documentation however, had not been signed or dated by the resident or her chosen representative. It is pleasing that the home had obtained information from the residents’ funding authority to aid the assessment of need and care planning processes. It is also pleasing that the home has produced a standard letter to inform prospective residents’ that their needs can be met by the home. A copy of this letter was on file for the newest resident. The new residents’ family had visited the home prior to her admission to assess the services provided. The home has a four week trial period in operation. This time given to enable both parties to determine the suitability of the placement before it is made more formal. Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 11 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. Work has been undertaken to improve care plans. The new care plan processes however, needs to be extended to all residents’. Improvements have been made in respect of healthcare provision however, fine tuning in some areas is still needed. Medication systems have improved in some areas however, further improvements are needed to ensure complete safety. EVIDENCE: It is pleasing that new care plan documentation has been produced and has been partially put into operation. The care plan document viewed are more comprehensive that the former version. The document contains provision for monthly reviewing of the care plans. There was evidence on three care plans seen to demonstrate that the resident or relative had been involved in the care planning process. It is positive that new digital weighing scales have been purchased by the new owners and are used to weigh the residents. Resident weight checking and monitoring has improved considerably. Written evidence was available to demonstrate that the new resident had been weighed on admission. All Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 12 residents’ are now being weighed at least on a monthly basis. Although a nutritional screening tool is now available within the home, there was a lack of evidence on three resident files that the tool had been used for them. Not all residents care plans to date have a dietary needs/ nutritional section included. A falls risk assessment process has recently been introduced. However, further development of these processes must be established to include referral to other agencies where concerns are identified an example being; the falls prevention team. The new resident has had three falls since admission, one other resident two falls in the last month. It is pleasing that input has been secured since the last inspection from the optician, chiropodist and dentist. A Commission for Social Care pharmacy inspection was carried out on 10 June 2005. The manager said she had not received a report following this inspection so a copy of the said report was provided to her during this inspection. Although medication systems have improved somewhat since the last inspection there is a lot more improvements required before medication systems can be deemed as effective or safe. It was pleasing to see that a revised medication policy has been produced to date however, procedures relating to medication errors and medication being taken out of the home have not been included in this policy. Similarly not all staff have read, signed and dated the policy. Evidence was available to demonstrate that prescribed topical preparations are now being signed for on medication records, as they should be, when applied. Work has commenced to ensure that an up to date list of current medications in respect of each resident is included in their care plan. As stated considerable further work needs to be undertaken in the area of medication safety. It is disappointing that a senior or other appropriate person has not been designated as having responsibility for medication management. Staff initial gaps are still occurring on medication records. It was noted that there was a discrepancy in running totals for a Nitrazepam liquid being prescribed for one resident. Staff have not all been deemed competent to carryout blood glucose monitoring, yet they are undertaking this task. It was noted that handwritten medication charts do not always contain adequate information, examples being allergies and doses. The manager confirmed that the home does not see all prescriptions. The present routine is that the dispensing pharmacist collects the prescriptions from the residents’ doctors then dispenses the medications, rather than the home receiving and checking the prescriptions before they go to the dispensing pharmacist. There was a lack of evidence to demonstrate that a risk assessment had been carried out in respect of (MW) who self medicates some prescribed products. Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 13 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): 14 Residents’ are helped to exercise choice and control over their lives. EVIDENCE: All residents’ bedrooms viewed held various personal effects including ornaments, pictures and electrical items. It was pleasing to see that an inventory with these personal belongings detailed was available on three of the four files viewed. The home has information pertaining to external advocate services available. Copies are generally displayed in the front entrance hall. It is pleasing that a copy of the homes access to records policy has been sent to relatives/ given to residents. Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Fine tuning of complaints procedures is needed to ensure that they are understandable to all. Residents’ continue not to be fully protected from abuse. EVIDENCE: The new organisation have revised the complaints procedure and has made this available to relatives. The complaints procedure has not however, been produced in a format appropriate to all residents’ such as; pictorial or large print. As previously stated the home has changed ownership since the last inspection. Although the new management have increased staffing levels and have arranged abuse awareness training for staff it is disappointing that incidents of physical abuse between a small group of residents’ are still occurring. More concerning is the fact that one incident occurred between two residents’ on 27 October 2005 yet staff did not report this directly to the manager. Consequently, this incident was not reported to the Commission for Social Care Inspection or Dudley MBC Adult Protection Co-ordinator. Further, an incident of restraint occurred on 4 October 2005, staff restraining a resident. The residents’ daily notes for this day read, “ B.. was very aggressive this morning when getting him up. It took 4 carers to wash and get him ready, all the time B.. was kicking out and would have been more physical if he had not been restrained”. There was no evidence that staff have received restraint training. The incident had not directly been reported to the manager or properly recorded. These incidents cause serious concern to the Commission Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 15 for Social Care Inspection. A serious concern letter has been issued to engender and ensure improvement. Staff are at the present time receiving further abuse awareness training. Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24. Work has commenced to improve the overall environment. This work however, needs to be completed before the home can be considered’ safe and well maintained’. Residents’ have access to safe and comfortable indoor and outdoor space. Work has been undertaken to improve bedroom facilities. EVIDENCE: It is extremely positive that the new owners have addressed many past requirements in terms of refurbishment and maintenance since they took over the home. Refurbishment work has been incorporated into a plan based on priority order. There is however, a lot of work still to be completed. The previous owners had not addressed refurbishment or redecorating needs for some considerable time. It is also positive that fencing and gates have been provided in the rear garden to enhance freedom of movement and safety. The lounges and dining room have been redecorated and have new floor coverings as have a number of bedrooms. These rooms look clean and bright Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 17 and are a big improvement. One resident commented, “ The dining room looks lovely now, a lot better”. The main hallway/ part of the ground floor corridor is being refurbished at the present time. When the redecoration has been completed laminate style floor covering is to be fitted. There was no evidence to demonstrate that an audit of each bedroom has been undertaken against standard 24. It is pleasing that new bed linen has been purchased and has been put into use. Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 18 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. Overall, staffing levels have improved since the last inspection. This enables residents’ needs to generally be met by staffing numbers provided. Residents’ generally are in safe hands. Fine tuning of recruitment practices is required to ensure that residents’ are fully protected. Further development is needed to ensure that staff are trained and competent to do their jobs. EVIDENCE: It is positive that care staffing levels have improved since the last inspection. This enhanced by the creation of new posts. A care manager has been appointed to assist the registered manager. A housekeeper and handyperson have also been employed. Staffing levels are evidenced by staff rota’s and are provided as follows; AM- one senior and five carers (plus the manger during the week). PM- One senior and four carers. Night time- One senior and two carers. The staff rota demonstrated that at times there is more than one senior on duty per shift. Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 19 The home provides domestic, laundry and catering staff daily. Staff spoken to were mixed about the new ownership. One staff member said, “ Things are done a lot more professionally now. Staff are observed and are supervised. Things are a lot better”. Another staff member said, “ There are a lot of changes without consultation. More established staff feel uptight and dread coming to work”. The home is well on target in respect of staff attaining N.V.Q level 2 or above in care. Recruitment processes have improved since the last inspection. Staff files viewed are now more organised. A number of shortfalls however, were identified in that there was no source of identity on a new members file and no job description or contract for another. Evidence was available to demonstrate that new staff in general are given induction instructions during their first few days of employment with the exception of the housekeeper. The home has opted to use the Mulberry House induction package for new staff. Training in a number of areas remains to be lacking examples being; violence and aggression, challenging behaviour and diabetes awareness. It is positive that a training plan is included on staff files and a training analysis has been carried out. Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 20 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): 31,33,36,38. Residents’ live in a home which is run and managed by a person who is fit to be in charge. Quality assurance processes need further development to ensure that the home is run in the best interests of the residents’. Fine tuning is required to ensure the health, safety and welfare of staff and resident’. EVIDENCE: The manager has managed care homes in the past and has been approved by the commission for Social care Inspection as a fit person to be in charge. The manager has a first level nursing qualification and remains on the Nursing and Midwifery Council register. It was not asked if the manager has attained N.V.Q Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 21 level 4 in management. If not then she must either complete the award or make moves to commence on a suitable course. It is positive that the manager was able to demonstrate that satisfaction questionnaires have been sent to relatives’ and residents’. A relatives meeting has been held since the new owners took over the home. The management confirmed that they will be using the Mulberry House quality assurance package/ monitoring system. This has however, not yet been put into operation. Staff files selected included evidence of recent one to one supervision sessions. A matrix system has been devised to ensure that all staff receive one to one supervision at least six times per year. Three residents’ money held in safe keeping was checked against balances. This was correct with the exception of 5 pence that had come out of the envelope. Evidence was available to demonstrate that 2 staff or 2 persons witness each transaction. At least one resident is encouraged and able to part manage their own money. A check was carried out on health and safety and maintenance certificates. There were service certificates available for all equipment with the exception of the portable hoisting equipment. The last portable electrical appliance test was carried out over twelve months ago. The manager did confirm that an electrician was visiting the home the following week to address this. It is pleasing that an accident analysis tool has been produced. This has not however, to date, been put into operation. Shortfalls remain in respect of staff mandatory training. There was evidence available however, to indicate that this is being addressed. As mentioned throughout this report refurbishment and re-decorating work is being carried out in various areas of the home. There was no evidence to demonstrate that risk assessments have been carried out. Dust sheets and trailing wires were seen which could potentially place residents’ at risk. Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 22 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 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 2 3 x x x 2 x x STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 3 x 2 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 23 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 finalise the homes statement of purpose and service user guide and put these into full operation. A copy of the finalised documents must be forwarded to the CSCI. The registered provider must ensure that a specific terms and conditions document is issued to service users who are funded by Social Services. (Timescale of 01/08/05 partially met). The registered persons must review and expand care plans to include long and short-term goals, all aspects of care ( mental health, social needs, diabetic care, oral care, communication, incontinence, aggression, pressure area care and others deemed as appropriate). ( Timescales of 01/04/05 and 13/08/05 partially met). Timescale for action 01/01/06 2 OP2 5(1)(b) 12/12/05 3 OP8 15(1) 12/12/05 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 24 4 OP8 13(3) The registered persons must expand the existing risk assessment proforma to include prevention measures such as hip protectors and nighttime pressure pads. ( Timescales of 01/05/05 and 13/05/05 not fully met). This process must also include referral to specialist fall prevention teams. 12/12/05 5 OP8 12(1) The registered persons must ensure that nutritional plans are established for service users’ with dementia. 12/12/05 6 OP8 12(1) ( Timescales of 01/04/05 and 13/07/05 not fully met). The registered persons must 12/12/05 carry out a nutritional screening using a recognised screening tool for individual service users’. ( Timescales of 01/03/05 and 13/07/05 not fully met). 7 OP9 13(2) The registered persons must; Provide sufficient and dedicated senior hours to manage and monitor the medication system to a satisfactory standard. Ensure that MAR sheets are maintained without gaps and completed signatures to indicate administration or appropriate codes to indicate nonadministration. (Timescales of 01/12/04 and 01/07/05 not fully met). 01/12/05 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 25 8 OP9 13(2) 9 OP9 13(2) The registered persons must carry out regular auditing of medication/ medication systems to ensure the integrity of the MAR charts is maintained. Evidence of these audits must be available for inspection. The registered persons must; Ensure that all medication received into the home is fully recorded including details of quantity, strength, dosage, and be signed and dated. Ensure that where variable doses are prescribed for example; ‘ one tablet or two’ the amount administered each time is recorded. Ensure that all short life preparations ( for example eye drops) are date labelled when opened. 01/12/05 15/11/05 10 OP9 13(2) 11 OP9 13(2) The registered persons must ensure that residents’ doctors’ confirm any changes to medication in writing before any changes are actioned. The registered persons must ensure that prescriber’s directions are adhered to without fail. If it appears that the directions are not appropriate for the circumstances then the doctor must be consulted. 15/11/05 15/11/05 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 26 12 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 in case of medication errors. This must include instruction that any medication errors must be reported to the CSCI in accordance with Regulation 37. Devise and implement a policy for any medication being taken out of the home for example; trips and outings. 15/11/05 13 OP9 13(2) The registered persons must; Ensure that all staff are able to operate the maximum and minimum medication fridge thermometer properly in order for temperatures to be recorded accurately on a daily basis. Ensure that the medication fridge is defrosted on a regular basis. 15/11/05 14 OP9 13(2) The registered persons must ensure that medication storage facilities are re-organised so that non- medicinal products are not stored with medications. 15/11/05 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 27 15 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. Ensure that only staff who have medication training are given responsibility for medications. ( Timescale of 13/06/05 not fully met). 01/12/05 16 OP9 13(2) The registered persons must 01/12/05 ensure that risk assessments are carried out for any service user who self medicates this including creams and inhalers. ( There was no risk assessment for MW). ( Timescale of 13/07/05 not fully met). The registered persons must retain an up to date list of medication for all service user’ in individual plans. ( Timescales of 01/02/05 and 13/07/05 not fully met). 17 OP9 13(2) 01/12/05 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 28 18 OP9 13(2) The registered persons must clarify all ‘ as directed’ doses with the doctor and add to the medication record administration record. ( Timescales of 01/04/05 and 01/08/05 not fully met). Ensure that the drugs trolley is kept clean with spillages wiped up promptly. To seek accredited training in the safe handling of medications for staff that administer medication. There was evidence available to demonstrate that attempts have been made to address this. The registered persons must; Ensure that staff receive training from an appropriate person for example, a district nurse, and are deemed competent in using blood glucose monitoring machines. And Confirm that medication training received by staff is accredited training. And Devise a policy for blood glucose monitoring. The registered persons must carry out an investigation into the discrepancy of the running total of the Nitrazepam syrup in respect of (FG). A written report of the findings and action taken to rectify must be forwarded to the CSCI. 01/12/05 19 OP9 13(2) 01/12/05 20 OP9 13(2) 20/11/05 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 29 21 OP9 13(2) The registered provider must; Ensure that all staff who have a responsibility for medications read, sign and date the homes medication policy. That the example staff initial list in respect of medication administration is complete and up to date at all times. 01/12/05 22 OP10 12(5) 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 and 13/07/05 partially met). 01/12/05 23 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 and 01/08/05 not fully met). The registered person must ensure that a dedicated activities 01/01/06 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 30 person is employed. 24 OP15 16(1)(i) 16(2)(g) The registered persons must ensure that consistent records are maintained of all service users’ preferred food options from the menu. ( Timescales of 01/04/05 and 13/07/05 not fully met). These must include at least 4 meals per day, breakfast, lunch tea and supper. The registered persons must ensure that the menu is appropriate to the residents’ needs for example, large print/ pictorial. 01/12/05 25 OP15 12(5) 20/12/05 26 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. 20/12/05 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 31 27 OP16 22(2) ( Timescales of 01/04/05 and 13/07/05 not met). The registered persons must ensure that the complaints procedure is produced in a format appropriate to the needs of the residents’ examples being, large print and pictorial. ( Timescale of 13/07/05 not met). The registered persons must ensure that all allegations of abuse are reported to appropriate agencies as per Dudley MBC adult protection guidance and Regulation 37 of the Care Home Regulations 2001. ( Timescale of 13/06/05 not fully met). This requirement has been subject to an enforcement notice issued to the former owner. Further noncompliance may result in similar action. 01/01/06 28 OP18 13(6) 31/10/05 29 OP18 13(6) The registered persons must carry out a full investigation to determine ( in respect of the incident of restraint on 4 October 2005); Why the restraint occurred; How the restraint was applied; Who authorised the restraint; Why a full record was not made; 10/11/05 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 32 Why the manager was not informed. A written report must be provided to the CSCI to include the outcome of the investigation which encompasses the above points and details action taken by the registered persons to address this serious concern. A serious concern letter was sent to the registered persons to this effect. The registered persons must ( in respect of (WL being slapped by another resident on 23 October 2005 ) ensure that; 24 hour monitoring of WL continues; That 1:1 staffing is provided for WL; That a risk assessment be carried out in respect of WL. A serious concern letter was sent to the registered persons to this effect. 30 OP18 13(6) 31/10/05 31 OP18 13(6) The registered persons must ( in 10/11/05 respect of the incident of abuse that occurred between NT and JC on 27 October 2005). Carry out a full investigation to determine; Why the manager was not directly informed of this incident; Why the CSCI was not informed of this incident; Why the incident was not reported in accordance with Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 33 Dudley MBC adult protection policies and procedures. A full report must be forwarded to the CSCI detailing the outcomes of the investigation and the actions taken. A retrospective Regulation 37 report must be forwarded to the CSCI with a copy sent to Dudley MBC adult protection coordinator. A serious concern letter was sent to the registered persons to this effect. The registered persons must ensure that; A senior person or manager scrutinises on a weekly basis all of the residents’ daily records to determine if any incidents of abuse or concern have occurred that have not been reported. Evidence must be available at all times to demonstrate that this is being done. Instruct all staff that any incidents of abuse or concern must be reported to the person in charge immediately. The registered persons must ensure; That the victim of any abusive action is cared for and appropriately supported. Ensure that measures are in place to prevent further abuse. Evidence of action taken etc must be available at all times. ( Timescale of 13/06/05 not fully met). Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 34 32 OP18 13(6) 15/11/05 33 OP18 13(6) 31/10/05 34 OP18 13(6) The registered persons must develop strategies for ensuring that staff remain familiar and understand the principles of vulnerable adult abuse policies. ( Timescale of 13/07/05 not fully met). The registered provider must upon identifying any residents’ you believe may be at risk from harm or abuse or any service user you believe may pose risk of harm or abuse to another service user(s) must carry out the appropriate actions from the following list or any others you deem as appropriate; Ensure that one staff member to one service user ratio is `provided during all waking hours and night time if you believe or have assessed that a service user may be at risk of harm or abuse or any service user you believe / have risk assessed as posing a risk of harm or abuse to another service user(s); That 24 hour behaviour / monitoring documents must be produced in respect of each resident you feel is at risk of harm or abuse. This must be completed each hour even if there is nothing significant to report, or immediately after an incident occurs. Give notice to the Commission for Social Care Inspection without delay of the occurrence of any allegation or incidence of abuse. These requirements were 15/11/05 35 OP18 13(6) 10/11/05 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 35 36 OP19 23(1) 23(20 included in an enforcement notice issued to the former owner on 1 July 2005 and must in abusive circumstances be followed again. The registered persons must; Progress with the provision of replacement carpet in the first floor corridors; Discuss the strip lighting in bedroom 34 with the service user with a view to providing a more appropriate source of lighting and to document the outcome in the service users’ plan; Seek advice from EHO relating to the ratio of the ramp to ensure that it is compliant with building regulations. To retain documented evidence of the outcome of this consultation. 01/01/06 37 OP19 23(2)(n) ( Timescales of 01/05/05 and 01/08/05 not fully met). It must be noted that the corridor has been stripped and is in the process of being replastered. The carpets will be replaced when this work has been competed. 01/01/06 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). Evidence was available to demonstrate that this process is well underway in respect of colours etc. Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 36 38 OP19 23(2)(b) The registered persons must fit suitable pass locks to all bathrooms and toilets. (Timescales of 01/04/05 and 01/08/05 partially met). There was evidence available to demonstrate that work on this is in progress. The registered persons must secure an appropriate structural engineer/ qualified person to assess ALL windows throughout the home with a view to replacement. A written report from this assessment must be forwarded to the CSCI with a timescale for action. ( Timescale of 01/08/05 not fully met). 01/01/06 39 OP19 23(2)(b) 01/02/06 40 OP21 23(2)(b) The registered persons must consider providing floor to ceiling doors/ partitioning in all toilets. The registered persons must provide new floor covering in room 22. (Timescale of 01/08/05 not fully met). It is positive that work in respect of this requirement is in progress. The registered persons must ensure that a lockable cupboard is provided in all bedrooms. (Timescale of 01/08/05 not fully met). Work is in progress in respect of this requirement. 01/02/06 41 OP21 23(2)(b) 23(2)(d) 01/01/06 42 OP24 23(2)(e) 16(2)(l) 01/01/06 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 37 43 OP24 16(20(i) 23(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 and 01/08/05 not fully met). This must include asking/ ensuring that light switches and electrical sockets are at heights suitable for each resident. 01/01/06 44 OP25 13(4) 23(4) The registered persons must ensure; That adequate heating is available at all times throughout the home. That a suitably qualified engineer must undertake a survey of the whole heating system. A written official report from this engineer complete with the findings from the survey must be forwarded to the CSCI. The registered persons must ensure that suitable thermometers be placed strategically around the home and that room temperatures are 15/12/05 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 38 taken and recorded regularly. ( Timescale of 13/07/05 not met). One resident told an inspector that she was cold during the previous night. 45 OP25 23(2)(p) The registered persons must ensure that the lighting in each room is measured and recorded in terms of lux effectiveness. The registered persons must continue to monitor the ventilation in the smoke lounge to prevent cigarette smoke/ odour emanating into other rooms. If the problem continues then more effective ventilation must be provided. 01/01/06 46 OP25 23(2)(p) 01/01/06 47 OP26 13(3) 48 OP26 13(3) The registered persons must ensure that mop heads are laundered daily at disinfectant temperatures. ( Timescales of 01/01/05 and 13/07/05 not fully met). The registered persons must contact the infection control agency in respect of MRSA in the home. ( Contact details for this were given to the manager during the inspection). 15/11/05 15/11/05 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 39 49 OP27 18(1)(a) The registered persons must produce and use a detailed dependence rating tool to determine residents’ individual dependency levels. (Timescale of 13/07/05 not met). The registered persons must continue to support and inform staff of any changes occurring to prevent any unrest. The registered persons must produce and implement a recruitment policy to accord with good practice, Department of Health POVA guidance and the Care Home Regulations 2001. 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. This to include a job description for the housekeeper. 01/12/05 50 OP27 12(5)(a) 15/11/05 51 OP29 19(4) 15/12/05 52 OP29 19(4) 31/10/05 53 OP29 19(4) To ensure that all staff receive terms and conditions of employment with a copy held on their personal file. ( Timescale of 07/07/05 not fully met). 30/11/05 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 40 54 OP30 17(2) 18(1)(a) The registered persons must 01/01/06 secure professional and accredited training for all staff on the subjects of ; Care planning; Record keeping. ( Timescale of 01/08/05 not met). Tissue viability training must be added to this list. This to include instruction not to erase writing with correction fluid. 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. ( Timescale of 01/08/05 not fully met). The registered persons must introduce a comprehensive kitchen cleaning schedule. ( Timescales of 01/04/05 and 13/07/05 not fully met). A cleaning schedule was seen but this is not being completed. 55 OP33 24(1)(2) (3) 01/01/05 56 OP38 16(2)(j) 01/12/05 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 41 57 OP38 13(4) The registered persons must ensure that a formal documented accident analysis is carried out on a monthly basis and action is taken to minimise any accident tendency. ( Timescale of 13/07/05 not fully met). A template has been produced for this purpose but not yet used. The registered persons must expand upon risk assessments in all areas; Behaviour; Aggression; Incidents of abuse; ( Timescales of 10/07/05 not fully met). To provide the following training for staff; Diabetes awareness. Understanding challenging behaviour and non- intervention techniques. ( Timescales of 01/04/05 01/12/05 58 OP38 13(4) 13(6) 01/01/06 59 OP38 13(4) 13(6) 01/01/06 60 OP38 13(4) 18(1)(a) and 01/08/05 not met). The registered persons must ensure that all staff have valid certificates or receive the following training ; First aid; Food hygiene; Moving and handling; 01/01/06 Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 42 Hoist usage. ( Timescale of 01/09/05 not fully met). 61 OP38 13(4) 23(2) 13(4) The registered persons must ensure that copies of service certificates for mobile hoists are forwarded to the CSCI. The registered persons must ensure that risk assessments are in place and are adhered to in respect of all work being carried out in the home. The registered persons must confirm with Dudley EHO / health and safety officer what qualifications are required for any staff member who has responsibility for health and safety in the home and whose name appears on the homes health and safety poster. 01/12/05 62 OP38 31/10/05 63 OP38 13(4) 18(1)(a) 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wordsley Hall DS0000065016.V260904.R01.S.doc Version 5.0 Page 43 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. 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