Inspection on 13/09/05 for Wrottesley House

This inspection was carried out on 13th September 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

Wrottesley House 04/09/06

Wrottesley House 02/03/06

Wrottesley House 20/01/05

Wrottesley House 24/08/04

Wrottesley House 05/02/04

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 Wrottesley House 46 Wrottesley Road Tettenhall Wolverhampton West Midlands WV6 8SF Lead Inspector Bhag Jassal Unannounced Inspection 13/09/05 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wrottesley House DS0000037696.V250765.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. Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wrottesley House Address 46 Wrottesley Road Tettenhall Wolverhampton West Midlands WV6 8SF 01902 744609 01902 744609/565522 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) Wrottesley House Ltd Mrs A Younger Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th January 2005 Brief Description of the Service: The home is situated in a residential area of Tettenhall about half of a mile from Tettenhall Green, and approximately three miles from Wolverhampton City Centre. The home is in close proximity to a main arterial road. The home was built over 25 years ago as a large, detached private dwelling and has since been adapted and extended to accommodate 18 service users. Six of the bedrooms have an en-suite facility. At the front of the premises there is a parking area together with flowerbeds and shrubs. The rear garden is well laid out with lawns and borders. There is one double bedroom and the remaining 16 bedrooms are single. The home has adequate bathrooms/showers and WCs. There are two lounges, a dining room, laundry room, an office and a staff room. Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 9.00 am and lasted 6 hours and 30 minutes. All 18 places were occupied. The inspection included discussions with the Registered Manager, staff, service users and their relatives/friends. The daily routines were observed and service users and staff records, policies and procedures were examined. The inspection of premises both inside and outside and facilities were also undertaken. What the service does well: Wrottesley House care home is registered for 18 older people. The home makes every effort to provide individuals with good standard of care to meet the assessed needs following a care plan. The home has a good key worker and supervision system in place. The home communicates well with families, friends and representatives. The visitors’ book indicated a lot of activities. The service users spoken with said that they are content, happy and enjoy living in a homely and caring home. Service users were in two lounges engaging in their daily activities and they further commented that they were comfortable and satisfied with the care provided. The Atmosphere within the home was observed to be relaxed, comfortable and friendly. The friendly rapport was also observed between service users and staff. Meals are varied, well balanced and presented to meet each individual’s choices, preferences and requirements. The home provides good standard of accommodation and facilities, which are being maintained safe, secure and comfortable for the use of service users and staff. Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The home must continue to improve and enhance the quality of care, and daily care recordings. The Registered Manager must ensure that the service users’ care plans are kept up to date and reviewed on a monthly basis. The records of social and leisure activities enjoyed by the service users must be maintained at all times and also incorporated into individual service users’ care plans. Those members of staff who as yet not received training in safe working practice topics, and training in safe handling of medication must do so as a matter of priority. This training would further enable staff to improve their care practices and professionalism. There are several small issues identified, which relates to the environment and these must be implemented to ensure a safe and comfortable environment for service users and staff. The Registered Provider must take appropriate and swift action to ensure the home is adequately staffed at all times and the two vacant posts of a senior carer and a carer are filled as a matter of priority. All members of staff must receive formal supervision at the required intervals. The Inspector would like to acknowledge the improvements made by the Registered Provider and the Manager since the last inspection. Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 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. Wrottesley House DS0000037696.V250765.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 Wrottesley House DS0000037696.V250765.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): 3, 5 and 6 The home has a good admission procedure providing effective needs assessment and suitability evaluation for both privately funded service users and those placed by the Local Authorities. EVIDENCE: A sample of three service uses’ care plans and files were examined in detail at the inspection. It was evidenced that all the service users received the benefit of a comprehensive assessment prior to admission. The Registered Manager also carryout assessments and these details are documented on care plans. The care plans are drawn up by the senior staff with the assistance from the service users and their relatives and where appropriate other professionals. There was evidence to show that all the service users have been provided with contracts. The home has a very good admission procedure, which is made available to all prospective service users and their relatives/representatives. The home does not offer an intermediate care service. Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 10 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 and 10 The staff within the home is aware and sensitive to the needs of each and all service users and meet their needs in a professional manner. There is a clear and consistent care planning system in place, which provides the information the staff requires to meet the service users’ health and care needs. EVIDENCE: It was evidenced that all the service users undergo a comprehensive assessment of their needs prior to admission. A care plan is produced, which is based on the assessment of needs. The home operates a key worker system, which helps to ensure that the recommendations arising from the care plans and reviews are implemented. Three service users’ care plans were examined in detail and these were not kept up to date and these have not been reviewed on monthly basis. The Registered Manager stated that all the care plans would be updated and reviewed within a week. The daily care recording formats were also examined and it was noted that the quality and details of recording need further improvement. The Registered Manager stated that the staff would be asked to make further improvements in care recordings. Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 11 The home also ensures that nutritional screening is is undertaken, including weight gain and loss records are maintained and appropriate action is taken if required. Case tracking demonstrated an effective review process together with the home’s ability to meet the changing needs as they occur. The service users’ health is closely monitored and appropriate medical care services are sought as and when required. It was observed on the day of inspection that no personal care interventions were taken in communal areas. In addition, consultation with health and social care professionals are carried out in the service users’ bedrooms. The Inspector spoke at some length with ten service users and all of them commented positively about their care and they felt that they have been provided with everything they need. Five service users stated “the carers are hard working and they look after us very well”. Two service users said “the carers are always there to help”. Other three service users said “these carers deserve big thank you and some sort of reward for what they do for us”. The Registered Manger stated that eight members of staff, including senior carers have completed their training in safe handling of medication, two members of staff are currently undergoing this training and others are being enrolled to undertake this mode of training shortly, subject to the availability of places. Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 Wrottesley House care home provides a good quality of care and promotes individual lifestyles for service users in residence. Service users maintain contacts where they wish with their family members, friends and local community. Meals at Wrottesley House are of good quality and homely type offering both choice and variety and catering for special needs. EVIDENCE: It was evidenced that the home provides an activities programme in accordance with the service users’ choices, preferences and capacities in relation to – social and leisure activities and cultural interests. However, it was noted that the records of activities enjoyed by the service users are not being recorded consistently. The Registered Manager stated that the staff would be asked to record all the activities provided and incorporated into all individual service users’ care plans. All the service users spoken to stated that they are in regular contact with their friends and family members, and spoke about visitors’ involvement and interest in their daily care matters. The visitors’ book kept in the home showed a considerable activity. Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 13 The relatives of three service users stated that they visit the home at various times of the day as they wish. All the relatives and friends who spoke to the Inspector said they are given warm and friendly welcome by the staff whenever they visit. The service users also keep contacts with the local community – for example, church services, shops, pubs and park. It was evidenced that the home provided a varied a varied, wholesome, and nutritious diet. The meals provided during lunchtime on the day of inspection were well received by the service users. The Registered Manager stated that the menu was revised in early September 2005, and this was done in consultation (meeting) with the service users. Several service users told the Inspector that the food was very nice, tasty, and well cooked. Several other service users also stated that the food was very good offering a good variety. The catering staff is well trained in food safety and hygiene matters. The kitchen is well equipped and kept clean and tidy. Wrottesley House DS0000037696.V250765.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 and 18 Concerns and complaints are dealt with promptly and professionally. The service users are protected from abuse by the home’s policies and procedures. The arrangements for the protection of service users from abuse are satisfactory. EVIDENCE: The home has very good Complaints Procedure, which is referred to for information in the home’s Service Users’ Guide and in the Statement of Purpose for the home. There is a system of recording concerns and complaints. However, it was noted that there were no complaints in the home and none directed to the Commission for Social Care Inspection. On the whole, all service users spoken with were very happy with life at the home. They said they knew whom they could speak to if they were worried about anything. The home has a policy and procedures in place with regard to the protection of service users from abuse. The Registered Manager stated that the staff has been made aware of the adult abuse and protection issues through induction training and several members of staff also have competed training on these issues. The Registered Manager stated that the remaining members of staff would receive this training shortly. Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 15 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, 21, 22, 24, 25 and 26 The general standard of the environment is very good providing service users with a homely and safe place to live. The good standard of cleanliness reflects the ongoing cleaning schedule, which maintains this standard throughout the home. EVIDENCE: The home offers a comfortable and well-maintained environment to all service users. The home has adequate communal space – two lounges and a dining room. The home is safe and is suitable for its stated purpose. The home has an ongoing rolling programme of redecoration to maintain good standard. The garden, patio and grounds are well maintained for the use of service users. However, the Registered Providers must ensure that carpets are replaced in the corridor leading to the Manager’s office and on the backstairs; and that the uneven floorboards in the corridor by the lift on the first floor are also repaired/replaced. All outstanding recommendations from the recent Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 16 respective inspection reports of the Fire Safety officer and the Environmental Health Officer are fully implemented as a matter of priority. The home has carried out a risk assessment of the premises and facilities by a qualified Occupational Therapist and a report was made available for inspection. The also home also has installed a loop system for the use of service users. The home has provided suitable aids and adaptations in the home to meet the general and specific needs of service users. However, the Registered Providers must ensure that suitable extractors fans are provided in the WCs, which presently are without this facility in the interest of hygiene. The unused stored furniture items must be removed from the bathroom on the first floor and this bathroom must be free for the use of service users. There is good standard of furniture and fittings provided in the service users’ bedrooms. It was noted that the bedrooms have been personalised by the service users. The level of lighting throughout the home was adequate and central heating system was working well. The fused light bulb in the staff room must be replaced. Hot water outlets in the service users’ bedrooms and in the communal areas are fitted with thermostatically controlled mixer valves. Hot water temperature is tested on a weekly basis and appropriate records maintained. However, it was noted that there was no hot water supply in bedrooms 7 and 8, which must be restored with immediate effect. A suitable thermostat must be fitted to the hot water tap in the wash hand basin in the kitchen used by the catering staff. All the radiators (with the exception of the radiator in the bathroom/WC used as en-suite for the bedroom next door) throughout the home are suitably covered/installed to ensure safety of the service users. During the day of inspection, the home was found to be clean and tidy and free from any unpleasant odour. The home has good policies and procedures regarding infection control. The Registered Manager stated that all staff is made aware of the dangers of cross-infection. It was evidenced that several members of staff have completed their infection control training and the remaining members of staff to undertake this training shortly. Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 17 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 and 30 The home is not adequately staffed at all times, which could impact the quality of care provided, and the ability of the home to meet the needs of the service users. The home continues to support staff to complete training. The home has good staff recruitment policies and procedures. EVIDENCE: On the basis of information provided by the Registered Manager and the available staff rotas indicated that the home does not meet the National Minimum Standard 27 and Regulation 18 of the Care Homes Regulations 2001. During the Inspector’s meeting with the staff on duty, they also stated that they are “pushed” at peak or busiest times of the day, and during the afternoon when the numbers of carers on duty reduces to two carers with a senior carer/manager on duty. The carers also expected to cover laundry, cleaning and catering duties, and in particular during the weekends and evenings. The home accommodates 18 service users with varying degrees of dependency levels. In addition, the Registered Manager stated that there are two vacant posts of a senior carer (38 hours per week) and a carer (30 hours per week). On the day of inspection it was noted that there were only two carers, a cook and the manager on duty. There were no cleaner and laundry assistant on Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 18 duty, and thus carers had to provide cover for these tasks in addition to their own caring duties. In order to cope with this difficult staffing situation, Mrs. Younger had to contact a carer to come out and assist the home on that day. The Registered Provider must ensure that there are minimum of two carers and a senior carer on duty throughout the day (i.e. mornings and afternoon shifts) and sufficient numbers of ancillary staff to adequately cover laundry, domestic and catering duties throughout the week. The Registered Manager’s hours are in addition to the above staff hours and should be considered supernumerary to allow her to manage the home effectively and efficiently. The Registered Provider must ensure that the vacant posts of a senior carer (38 hours per week) and a carer (30 hours per week) are filled as a matter of urgency and priority. It was evidenced from the staff training records that six members of staff have completed their NVQ Level 2 training. The Registered Manager stated that currently four carers are undergoing this mode of training and the remaining carers are being enrolled to undertake their NVQ Level 2 training shortly. There are three carers who have completed their NVQ Level 3 qualification. There are several carers who have completed their Dementia care training. The Registered Manager stated that all new members of staff now receive the TOPSS Induction and Foundation training. The home has a good staff training programme in place. However, the Registered Provider must ensure that all those members of staff who as yet NOT received safe working practice topics (i.e. moving and handling, food hygiene, first-aid and infection control etc.) training must do so as a matter of priority. Discussion with the Registered Manager and examination of the most recently recruited staff files demonstrated that thorough recruitment procedures had been followed in line with the home’s recruitment policy. Two written references and enhanced CRB and POVA checks are being undertaken before new staff actually commences their duty. The Registered Provider must ensure that all members of staff have their photographs on their individual files. The Registered Manager and the Registered Provider are aware that any member of staff with criminal records would not be employed in accordance with the Department of Health Guidance issued in July 2004. Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 The home is managed by an experienced Registered Manager, who lead the group of staff with a great deal of confidence. The staff is clear of their roles and responsibilities. Good systems of communication are in place to seek views of the service users and their families/friends. The service users’ monies are appropriately handled by the registered Manager. The staff is regularly supervised to enable them to carryout their work professionally. Health, safety and welfare of service users and staff are promoted by safe working systems put in place by the Registered Provider and the Manager. Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 20 EVIDENCE: The Registered Manager has completed her RMA training course and she is due to complete her NVQ Level 4 in care and management qualification shortly. Mrs Younger has initiated a number of changes in order to improve further the care practices and recording formats to enhance the high quality of care for the service users. The home has quality assurance system in place. The Registered Manager stated that she is to undertake the annual review of the home’s quality assurance plan (for the year 2005), which would be completed in October 2005. The home has good financial procedure in place. The home assists a number of service users with their money. There is safe in the home for storage of money and valuables. A sample of three service users’ money was checked and found to be satisfactory. The records of all financial transactions are appropriately maintained. It was evidenced that not all staff have received their required numbers of formal supervision meetings. The Registered Manager stated due to staff and management changes in the home this area of activity had lapsed, but now it would be fully implemented. The Registered Provider must ensure that window restrictor in bedroom 19 is fitted appropriately; and that the fire risk assessment is updated and any risks identified must also be rectified. All those members of staff who as yet NOT received the safe working practice topics training must do so as a matter of priority. Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 3 X 3 2 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 22 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 OP7 Regulation 15 Requirement Timescale for action 15/12/05 2 OP12 3 OP19 4 OP21 The Registered Manager must ensure that the service users’ care plans are kept up to date and reviewed on a monthly basis; and that appropriate action is taken to improve the quality of daily care recordings. 12,14 &16 The Registered Manager must ensure that the records must be maintained of all the social and leisure activities enjoyed by the service users. 23 The Registered Provider must ensure that the carpets are replaced in the corridor leading to the Manager’s office and the backstairs; and that the uneven floor boards in the corridor by the lift on the first floor are appropriately replaced/repaired for the safety of service users and staff. All the outstanding recommendations arising from the recent inspection reports of the Fire Safety Officer and the Environmental Health Officer must be addressed as a matter of priority. 23 The Registered Provider must DS0000037696.V250765.R01.S.doc 15/12/05 31/12/05 31/12/05 Page 23 Wrottesley House Version 5.0 5 OP25 13 & 23 6 OP27 18 7 OP27 18 ensure that suitable extractor fans are provided in WCs, which are presently without this facility in the interest of hygiene and unpleasant odour in the home; and that the unused furniture items stored in the bathroom on the first floor are removed and to make this bathroom free for the use of service users. The Registered Provider must 31/12/05 ensure that the hot water supply is restored in bedrooms 7 and 8 as a matter of priority; and that a suitable thermostatically controlled mixer valve is fitted to the hot water outlet (i.e. sink used by staff for hand washing) in the kitchen, and that the uncovered radiator in the bathroom/WC used as en-suite facility next to bedroom is covered appropriately as a matter of priority for the safety of the service users. The Registered Provider must 15/12/05 ensure that the vacant posts of a senior carer (38 hours per week) and a carer (30 hours per week) are filled as a matter of priority. The Registered Provider must 15/12/05 ensure that there are minimum of two carers and a senior carer on duty throughout the day, and sufficient numbers of ancillary staff to adequately cover laundry, cleaning and cooking duties throughout the week for 18 service users with varying degrees of dependency levels and accommodated on two floors. The Registered Manager’s hours are in addition to the above staff hours and should always be considered supernumerary to allow her to manage the home effectively and efficiently. DS0000037696.V250765.R01.S.doc Version 5.0 Page 24 Wrottesley House 8 OP28 18 9 OP29 19 10 OP30 12 & 18 11 OP31 9 12 OP33 24 13 OP36 18 14 OP36 4, 12, 13 & 23 The Registered Provider must ensure that there is a minimum ratio of 50 trained members of staff NVQ Level 2 or equivalent by the end of 2005. The Registered Manager must ensure that all staff employed in the home have their photographs on their individual files. The Registered Provider must ensure that all those members of staff, who as yet NOT received the safe working practice topics training must do so as a matter of priority. The Registered Provider must ensure that the Registered Manager completes her NVQ Level 4 in care management by the end of 2005. The Registered Provider must ensure that the home’s Quality Assurance Annual Plan for the year 2005 is fully implemented. A report of the analysis of the feedback on the quality of services and facilities provided by Wrottesley House must also be made available in the home and for inspection by the Commission for Social Care Inspection. The Registered Manager must ensure that all members of staff receive formal supervision six times a year. The Registered Provider must ensure that a window restrictor is fitted to window in bedroom 19; and that the fire risk assessment is updated and any risks identified must be rectified, and all those members of staff, who as yet NOT received training in safe working practice topics must do so as a matter of priority. DS0000037696.V250765.R01.S.doc 31/12/05 15/12/05 31/12/05 31/12/05 31/12/05 15/12/05 31/12/05 Wrottesley House Version 5.0 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP30 Good Practice Recommendations The Registered Provider should consider that the care staff, who as yet not received training in safe handling of medication should do so as soon as practicable. The Registered Provider should consider making provision for training for staff in adult protection, dementia care, and disability awareness. Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wrottesley House DS0000037696.V250765.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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