Inspection on 29/04/08 for Wordsworth House

This inspection was carried out on 29th April 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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22 Sandown Road

The Highlands

Turret Villa Retirement Home

Dilston College Of Further Education

West View House

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Park View (15)

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Wordsworth House Clayton Road Jesmond Newcastle Upon Tyne Tyne & Wear NE2 1TL Lead Inspector Alan Baxter Key Unannounced Inspection 29th April and 1st May 2008 09:30 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 Wordsworth House DS0000070965.V358462.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. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wordsworth House Address Clayton Road Jesmond Newcastle Upon Tyne Tyne & Wear NE2 1TL 0191 212 1888 0191 281 3764 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) Southern Cross BC OpCo Ltd Christine Helen Condon Care Home 78 Category(ies) of Learning disability (4), Old age, not falling registration, with number within any other category (78) of places Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 78 2. Learning Disability - Code LD, maximum number of places 4 The maximum number of service users who can be accommodated is: 78 N/A (newly registered service) Date of last inspection Brief Description of the Service: Wordsworth House is a purpose built care home situated in Jesmond, a residential suburb of Newcastle. It opened in 1989 and is now owned by Southern Cross. The home has seventy-eight beds and offers both nursing and residential care. All bedrooms are single and are spread over three floors. There are 19 bedrooms with en-suite facilities. There are large lounges and dining rooms on each floor plus assisted bathing and toilet facilities. There is a private chapel, hairdressing and activities room. A passenger lift accesses all resident areas. There are extensive landscaped gardens with patio and decking areas that are easily accessible. Car parking is available at the front of the building and the home is close to main bus routes and a Metro Station. The fees for the home are £383 to £647 per week. Further information about the home is available in the service user guide, which contains the statement of purpose and previous inspection reports. This is kept in the reception area of the home. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. How the inspection was carried out Before the visit: We looked at: • Information we have received since the home was registered by the current owners, Southern Cross BC OpCo Ltd., in November 2007. • How the service dealt with any complaints & concerns since then. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 29/04/08, with a follow up visit on 1/05/08. During the visit we: • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since registration. We told the manager what we found. What the service does well: Feedback from residents and families is very positive. One person commented, “We looked at loads of other homes before coming here. We are staggered by the amount of good care, here. Nothing is too much trouble, but without being patronising”. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 6 The home provides enough information about the service to allow people to decide if the home can meet their needs. It will then only admit someone if a full assessment has been carried. It also gives new residents written information as to their terms and conditions. For every need a resident has, the home draws up a detailed plan of how it is going to meet that need. Health care needs, including the giving of any prescribed medications, are fully met. Residents are treated with respect and dignity. The home has an excellent commitment to providing regular, varied group activities, but also makes sure that residents have someone to talk to on an individual basis. Families and friends are encouraged to keep in regular contact with the residents, and residents are helped to keep in contact with their local community. They have a good degree of choice as to how they spend their time, and enjoy a good diet, with plenty of choice. The home takes all concerns or complaints very seriously, and looks into them carefully. It also gives staff good quality training in how to protect residents from abuse or harm. The home is kept in a good physical and decorative condition, and is well maintained, as well as being kept in a clean and attractive condition. There are good levels of staff and a high proportion of staff are qualified. The home selects its staff carefully and gives them a good level of training. The manager is suitably qualified and experienced to run the home. The manager makes sure that staff are properly supervised and that the health and safety of both residents and staff are protected. There are systems in place to ask the opinions of those who use the service and their views are taken seriously and are acted upon. What has improved since the last inspection? What they could do better: The dining arrangements for those residents who use wheelchairs must be reviewed and improved. Unsafe corridor carpets must be replaced. The recording of residents’ financial transactions should be made more detailed. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 7 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. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 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 Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. People who use the service experience good quality outcomes in this area. The home gives out detailed information about the services offered so that any one thinking of coming into the home can decide if it will meet their needs. A statement of terms and conditions (or a contract, for privately-funded residents) is issued on admission to the home. A full assessment of a person’s needs and wishes is carried out before a place in the home is offered, to make sure those needs can be met. We have made this judgement using available evidence, including a visit to this service. EVIDENCE: The home’s Statement of Purpose and its’ Service User Guide are clear, detailed and up to date. The ‘aims and objectives’ section stresses the need to value each service user’s needs and values regarding their religion, culture, race, sexuality etc. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 10 Of the 20 surveys returned by residents, 18 said that they had been given enough information to make an informed decision about whether or not to come into the home. One person commented, “Full information given during visit prior to admission. Better level of information than other homes visited/considered”. Only one person stated that he/she had not been given a statement of terms and conditions, or contract, since coming to the home. The home’s manager carries out very detailed pre-admission assessments. The assessment is comprehensive, covering, for example, skin care needs, continence, nutrition, dependency and moving and handling needs. In addition, the manager makes sure that the person making the referral to the home also supplies a full assessment of needs. This allows her to judge whether or not the home can meet all the person’s needs. There is a re-assessment of needs every month, to make sure that they are still being met, and a formal review of care every six months. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. Clear systems around assessing and planning care ensure that staff work with current and detailed information to guide delivery of care in a dignified way to people using the service. We have made this judgement using available evidence, including a visit to this service. EVIDENCE: Draft care plans are drawn up, based on the pre-admission assessments carried out with the resident or family, and are put in place before a new resident is admitted. More detailed care plans are put in place after admission, as the staff get to know the resident better. Care plans are clear and comprehensive, and are evaluated as often as is necessary (daily, if required). This ensures that staff work with current information about the person and are better able to respond to their needs. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 12 In a survey, all 20 residents who responded said that they either ‘always’ (12) or ‘usually’ (8) get the care and support they need. Residents sign that they agree with the content of their care plans. Care plans stress the need to protect the privacy and dignity of the residents. Residents’ health care needs are fully assessed during the home’s preadmission assessment. Other, more specialised, health assessment tools are available to be used where necessary. These include bowel assessment, nutritional screening, etc. Similarly, specialist care plans are drawn up to meet specific health needs, such as wound care. Other records are on file to record elimination, turning, challenging behaviours, Diabetes care etc. There was ample evidence of referral onto the normal range of health professionals, including specialists; and details of visits and appointments are well recorded. In a survey, 17 of the 20 who responded said that they always receive the medical support they need; 3 said ‘usually’. The home uses a monitored dosage system, which the manager believes offers better stock control and easier auditing of drugs. There is a daily drugs audit on staff handover, and a monthly audit of 25 of residents’ Medication Administration Records (MAR). The MAR sheets are fully completed and are up to date. They include photographs of residents to minimise the chances of giving medicines to the wrong person, and written permission from doctors about individual residents taking non-prescribed (or ‘homely’) medicines. Storage of medicines is acceptable in terms of security, but the temperature of the medication storage room was unacceptably hot, at 26 degrees Centigrade. The manager took immediate steps to procure some ‘cold air’ radiators, which resolved the problem. As noted in the statement of purpose, above, the home recognises the need to protect the privacy and dignity of its residents. This was confirmed in the residents’ care records, which are sensitive and respectful, and also by conversations with residents, who felt they are always treated with courtesy and respect by all the staff. The fact that bedroom doors are fitted with doors that are connected to the home’s fire alarm system, and would thus shut automatically if the fire alarm went off, means that residents can choose to have their bedroom doors open during the day. A large number of residents’ doors were open, including a Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 13 number where the resident was seen in bed. It was accepted that this is down to the individual choice of the resident, but the manager agreed to carefully monitor that this choice is continually kept under review, and never allowed to become routine practice. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 14 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 and 15. People who use the service experience good quality outcomes in this area. People using the service are well supported to continue to make decisions affecting their daily life experiences and keep any contacts with family/friends and the local community. We have made this judgement using available evidence, including a visit to this service. EVIDENCE: The home employs a full-time diversional therapist, who organises the activities and social opportunities for the home as a whole. At the request of the residents, the home also employs a part-time ‘companion’, whose role is to provide more individual social contact with residents. The company is complimented on this is excellent practice, as it demonstrates that residents have been listened to. There is a varied twice-daily programme of social events and activities, which is clearly advertised and promoted around the home, and a copy of the programme is made available to each resident in his or her bedroom. Again, good practice. The activity schedule includes exercises, film shows, quizzes, bingo, ‘pat a dog’, various games, and crafts. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 15 There is also a monthly visit by an entertainer, a weekly mobile shop, occasional clothes parties, a visiting artist who works with the residents and an ‘art gallery’ area to display residents’ work. There is a good knowledge of residents’ individual likes, dislikes, hobbies and interests, and the diversional therapist and companion work together to meet individual residents’ social and recreational needs, including celebrating residents’ birthdays. There is weekly communion for Catholic residents, and a monthly Church of England service. The home has converted two rooms to form a chapel. Of the 20 residents who returned surveys, 15 said that there was always or usually activities they can take part in; and 5 said there ‘sometimes’ are activities. Comments included, “The activities are very good”, “If well enough to take part, good range of activities”, and “Having Dementia it is difficult to join in so life can be very lonely”. The home welcomes families, friends and other visitors to the home. Residents may choose whom they see and don’t see; and may see their visitors in the privacy of their own room, if they wish. There is a weekly trip out, in the home’s own minibus. One resident commented, “Would like more opportunity for more frequent visits in the minibus”. Another asked for more capacity for wheelchair-bound residents in the minibus. A recommendation is made in this report to this effect. Eighteen people said that the staff listen to them, and act upon what they say (2 didn’t answer this question). Discussion with residents during the inspection confirmed that residents feel listened to by the staff and the manager. They also confirmed that they are encouraged to make their own decisions about their daily routines, when to get up and go to bed; what to wear; what to eat; when to bathe etc. Menus are varied, appealing and nutritious. The home is open to and responsive to residents’ menu requests. For example, residents asked for kippers for breakfast, and were very pleased that this has been provided. Of the 20 residents who returned surveys, 16 said that they either ‘always’ or ‘sometimes’ enjoy their meals; and 4 said they ‘sometimes’ enjoy them. Comments included, “ Most of the meals are very good”, “…food … is usually cold when it is served”, “Like the meals very much indeed” and “Very repetitive”. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 16 A meal was taken with the residents. The meal was hot and enjoyable. Residents spoken with said they enjoyed their meals. Tables were pleasantly set, but were unsuitable for people using wheelchairs, who were unable to get close enough to the tables for comfort and ease of eating. A requirement regarding this is made in this report. Drinks were served in plastic glasses, which were marked and opaque. Cutlery was mismatched and some was difficult for some service users to use. A recommendation regarding this is made in this report. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 17 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 and 18. People who use the service experience good quality outcomes in this area. The home adopts a positive approach to dealing with complaints/ dealing with allegations of abuse and as part of their overall commitment to improve the quality of the service for people. This ensures that people are listened to and not placed at risk of harm. We have made this judgement using available evidence, including a visit to this service. EVIDENCE: The home records all complaints or concerns, however, minor. There have been five entries in the complaints record in the past year. Of these, four were not substantiated (although the home amended some systems in the light of the complaints). One complaint, regarding a food issue, was upheld and an apology given to the resident. All were taken seriously and were properly recorded, with clear outcomes. All 20 residents who returned surveys said they knew who to speak to if they are not happy, and all but 2 said that they knew how to make a complaint. In conversation, residents all said that they feel that the staff listens them to. The home has appropriate policies and procedures for preventing harm coming to its residents; and for responding to any allegations of mistreatment. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 18 Discussion with the manager and some staff confirmed that they are aware of, and when necessary use, the proper channels for reporting any allegation of abuse. Three such allegations have been received in the past year. One resident reported being scared of a carer because this person mimicked another resident’s way of expressing his/herself. This was reported properly and promptly to Social Services. The manager was asked to investigate the allegation. She found it to be partly substantiated. The carer resigned. A second allegation, of poor care practices, was also properly reported and investigated. This was substantiated. The third situation involved an altercation between two confused residents resulting in both falling and one sustaining an injury. Again, the proper procedures were followed. The situation was resolved. All staff are being given twelve days ‘safeguarding’ training by the end of this year (24 staff have already completed this course). Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 19 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 and 26. People who use the service experience good quality outcomes in this area. People have a safe and well-maintained living environment. clean, pleasant and hygienic. The home is We have made this judgement using available evidence, including a visit to this service. EVIDENCE: Communal areas of the home were inspected, as were some bedrooms (with the permission of their residents). Nearly all areas seen were apparently safe, and were well maintained. The only significant area for concern was the need to replace the ground floor corridor carpets, as they are a trip hazard to residents, especially those with poor mobility. A requirement is made regarding this issue in this report. Three bathrooms have been upgraded over the past year, with fully tiled ‘walkin’ showers fitted. Toilets have been redecorated and re-floored. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 20 One resident requested more parking spaces for visitors. The manager agreed with this point and is negotiating some extra parking spaces with the company. All areas of the home seen were in a clean and attractive condition. Of the 20 residents who returned surveys 16 said that the home is ‘always’ fresh and clean; the other 4 said it ‘usually’ is. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 21 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 and 30. People who use the service experience good quality outcomes in this area. Good staffing levels, and the high proportion of qualified staff, mean that the needs of the residents are being met. Residents are protected by the home’s careful staff recruitment policies and practices. Staff are well trained and are competent to do their jobs. We have made this judgement using available evidence, including a visit to this service. EVIDENCE: Study of the staff rosters and care records, and discussion with the manager confirmed that the staffing levels at the time of this inspection were meeting the needs of the service users. Of the 20 residents who returned surveys, 10 said that staff are always available when they needed them; 10 said that the staff are usually available. Comments included, “Sometimes there is a little delay”, and “ I think staff are often overworked due to sickness”. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 22 Of the 42 care staff, 32 hold the National Vocational Qualification (NVQ) level 2 in care, and 3 more are currently studying for this award. In addition, 6 care staff also hold the higher NVQ level 3, and 6 more are studying for this. This means that 75 of care staff are qualified. This exceeds the required minimum of 50 . There is a thorough staff recruitment procedure in place. Applicants have to submit a fully completed application form that lists their work history and requires them to make a declaration regarding any previous convictions. Checks are made with the Criminal Record Bureau (CRB) and two written work references are always taken up. Proof of identity is required. Minutes are kept of all interviews, and any gaps in the application form or any other anomalies are discussed with the applicant. All these checks are to ensure that applicants who are unsuitable to work with vulnerable people are not employed. The company is an Equal Opportunity employer and will employ people with disabilities. Induction training is given to all new staff, with carers receiving their induction training over a period of twelve weeks. This training is recorded. The individual’s further training needs are identified at the end of their induction; and at their annual appraisal, thereafter. Mandatory training (that is, training required by law) is up to date for all staff, according to the current expectations. The new company, however, is introducing a higher standard, in that its policy is to give mandatory training to all staff every year. All staff are therefore currently going through ‘refresher’ training courses in moving and handling; fire safety; infection control; safeguarding of vulnerable adults and first aid. This is planned to be completed by the end of this year. Specialist training, to meet individual residents’ needs or for staff personal development, is also given. Examples seen included training in Dementia care, schizophrenia, dysphasia awareness, challenging behaviours, wound management, palliative care and the promotion of continence. Training certificates are on file. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 23 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 and 38. People who use the service experience good quality outcomes in this area. The current manager is suitably qualified and experienced to run the home. Good systems are in place to gather the views of the residents and their families, and evidence that these views are acted upon. Despite the current difficulties of changing accounting systems, residents’ financial interests are being protected. Staff are regularly and appropriately supervised. The health, safety and welfare of the residents and staff are promoted and protected. We have made this judgement using available evidence, including a visit to this service. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager at the time of this inspection, Mrs Christine Condon, has eleven years managerial experience and holds both Registered General Nurse and Registered Manager Award qualifications. Before this inspection she had a made a positive choice to return to the deputy manager post, to give her a more active role in the day-today care of the residents. A new manager, Mr A. Olsen, is due to take up post on 7th May. A range of quality assurance systems is in place. A residents’ survey is conducted every six months, and the results collated and published. Meetings are held every six weeks with the residents and their families, chaired by the manager personally and minuted. There is a suggestions box in the entrance lobby. A food questionnaire was recently circulated. The manager, who has an ‘open door’ policy for residents and relatives, handles individual queries. There was good evidence that the management of the home is responsive to the feedback gained by the above systems. Items raised in meetings are put on the agenda for the following meeting, to make sure they have been addressed. Improvements to the service as a result of feedback includes the changing the nurse call system to ring only on the floor where it is activated, rather than throughout the home; changes to menus and the provision of better hot food trolleys; changes to the environment (new floor coverings); and more equipment for social activities. Of the 20 residents who returned surveys, 18 said that the staff listen to them and act upon what they say. The home’s ‘Service Users’ Guide’ clearly states the new company’s policy regarding residents’ finances. This is that a ‘pooled facility’ for residents’ personal monies is offered, up to a maximum of £500. It pays no interest, but charges no bank charges. For amounts in excess of £500, a designated bank account would be opened. This will be a fully computerised system. However, some problems are being experienced as the home changes from the current system of paper accounts and of individually held cash sums for each participating resident, to the new computerised system. In particular, there appears to be a cash flow problem. It was recommended that more detailed recordings are necessary in the individual accounts, so that the steps being taken to deal with the cash flow problem are completely transparent. Receipts are kept. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 25 There is a clear system for the staff supervision. All qualified staff and care staff receive supervision every two months, planned in advance. The manager currently supervises nursing staff and some care staff; the deputy manager shares the responsibility for supervising care staff. Supervision sessions are formally minuted and are signed by both parties. Ancillary staff are supervised on a day-to-day basis. This is not recorded. There is a comprehensive Health and Safety policy and procedure in place, with a named person responsible for health and safety within the home. Risk assessments are in place, and these are also comprehensive. The fire risk assessment is reviewed annually. Fire safety records show that all the necessary checks and tests of fire equipment and systems are undertaken at the appropriate intervals, as are fire drills. There is an ‘emergency evacuation folder’ in place in the foyer, and the manager updates the information in this daily. There are thorough and detailed records kept of maintenance in the home. Information about the control of substances hazardous to health is displayed appropriately around the home. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 26 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 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 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 3 Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A (new service) 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. 2. Standard OP15 OP19 Regulation 23.2 23.2 Requirement Dining arrangements must be suitable for persons who use wheelchairs. Ground floor carpets must be replaced. Timescale for action 31/07/08 30/09/08 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 OP15 OP35 Good Practice Recommendations Plastic glasses and cutlery should be replaced. More detailed recording is recommended in the accounts held for residents’ money. Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Wordsworth House DS0000070965.V358462.R01.S.doc Version 5.2 Page 29 - 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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