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Inspection on 15/11/05 for Wrottesley Park House Nursing Home

Also see our care home review for Wrottesley Park House Nursing Home for more information

This inspection was carried out on 15th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 24 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

A visitor to the home commented to one of the inspectors that some of the staff at the home are "golden" and committed to the welfare of the residents, although also stating that others appear uninterested and incompetent. A visitor commented that the catering staff are good, and will prepare different foods to try to meet individual preferences or persuade someone who is unwell to eat.

What has improved since the last inspection?

Training has been provided for some staff relating to the needs of people with a learning disability and two of the senior staff are undertaking training in this field. Risk assessments were found in care files relating to use of bed rails and wheelchairs. The provision of notifications to CSCI of incidents and accidents has improved. Contracts are now drawn up between residents and the home to ensure that residents and/or their representatives are aware of terms and conditions of occupancy

CARE HOME ADULTS 18-65 Wrottesley Park House Nursing Home Wergs Road Tettenhall Wolverhampton West Midlands WV6 9BN Lead Inspector Ros Dennis Announced Inspection 15th November 2005 10:00 Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 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 Park House Nursing Home DS0000036983.V267282.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 Adults 18-65. 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 Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wrottesley Park House Nursing Home Address Wergs Road Tettenhall Wolverhampton West Midlands WV6 9BN 01902 750040 01902 755510 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) Abbey Healthcare Homes (Wrottesley Park) Ltd Care Home 57 Category(ies) of Learning disability (57), Physical disability (57), registration, with number Terminally ill (57) of places Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th July 2005 Brief Description of the Service: Wrottesley Park House is a care home providing accommodation, personal and nursing care to 57 adults. It is registered to offer services to people with physical disabilities, learning disabilities and people who require palliative care.It is owned by Abbey Healthcare (Wrottesley Park) Limited. It is located on the main A41 Albrighton/Telford road out of Wolverhampton on the Wergs Road, half a mile past Tettenhall Village Green. It is a purpose built home with three residential areas on the ground floor, each having fifteen private bedrooms and communal areas. The first floor has twelve bedrooms. All bedrooms have en-suite facilities and include a shower. Services such as catering, laundry and cleaning are provided in-house. There is a passenger lift for accessing the first floor. There is extensive car parking facilities, and easily accessible gardens. The home has recently increased the number of bed rooms within the property, however these six bedrooms have not yet been registered for use via CSCI. Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place over some seven hours, conducted by two inspectors, Ros Dennis, Lead Inspector for the home and Deb Holland, Regulation Manager. The purpose of the inspection was to focus on the requirements of previous inspections and to monitor progress against an action plan submitted by the provider in response to those requirements. The home is in a state of some change, having recently appointed a new acting manager to replace the previous manager whose application for registration had been refused by the commission. The provider has also obtained a completely new set of documentation for the home which is yet to be put into practice. Some issues raised in previous inspections were found not to have been addressed, including unsafe hot water temperatures, inadequate staff recruitment procedures, failure to ensure the safety of the use of bed rail provision and the continued failure for care records to reflect and/or promote the needs of the people accommodated at the home. Overall this home is considered not to be functioning at an acceptable level and improvements are required urgently in order for the provider to avoid statutory action. What the service does well: What has improved since the last inspection? Training has been provided for some staff relating to the needs of people with a learning disability and two of the senior staff are undertaking training in this field. Risk assessments were found in care files relating to use of bed rails and wheelchairs. The provision of notifications to CSCI of incidents and accidents has improved. Contracts are now drawn up between residents and the home to ensure that residents and/or their representatives are aware of terms and conditions of occupancy Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 6 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. Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5 Admissions to the home have been made without there being the quality and quantity of staff and the resources to meet the person’s assessed need. EVIDENCE: The home’s statement of purpose and service user guide is being developed with the assistance of a consultant, who met inspectors briefly at this inspection. It has been established that the home has admitted people outside its registration, for instance, people who have mental health problems and people who have a sensory impairment as the primary factor in determining their need for residential care. The home has submitted an application to vary their registration to accommodate one person with mental health needs which is being considered by the commission. It was unclear what assessment tool had been used to inform the admission of a person who is registered blind admitted in August 2005. The falls risk assessment for this person was non-specific and not geared to the needs of someone registered blind. There was no evidence that the service for this person is based on specialist and/or clinical guidance, and the staff group has not undertaken training to support care of people with mental health problems or sensory impairments. It was reported that all current residents’ statements of terms and conditions have been drafted and most have been signed off. Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Care plans are insufficiently individualised and do not accurately reflect the changing needs or personal goals of service users. EVIDENCE: The care plans for three individuals cared for on “yellow” wing were scrutinised in detail. One referred to the person registered blind whose assessment is commented on earlier in this report. The care plan recorded reviews being conducted in August, September and November 2005. The diabetes care plan did not specify the frequency of monitoring that should take place. The plan for this person’s mobility was personalised, but the social care plan was nonspecific and bore no relation to this person’s history or individual interests. The assessment information and care plan recorded that this person is diabetic and has high blood pressure and that one of the aims of the plan is to “maintain normal body weight”. The recorded conclusion elsewhere in the record that this person had gained 17kg between August and October 2005 had not triggered any amendment of plans or review of care. The plan for a service user who is a wheelchair user was examined. The Waterlow score for this person appeared inaccurate as did not recognise that the person is “chairbound”. The Waterlow assessment described a pressure Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 10 sore assessed as Grade 2 becoming apparent in August 2005 and the service user’s own perception of the pain score was the highest score. The pain care plan is unspecific and not individualised for this service user or the treatment provided. There was no care plan on file for the pressure sore but a dressing chart in a separate file described the regime and frequency of dressing changes required. This stated that the dressing should be changed every two days and these records dated back to June 2005, with necrosis noted in July and seen by the Tissue Viability Nurse. The record in the dressing chart (amended in August to state dressing should be renewed every 2-3 days) does not evidence that the dressing has been attended to at the required regularity, for instance 11.6.05 – 16.6.05; 14.7.05 – 18.7.05; 22.7.05 – 26.7.05; 26.7.05 – 30.7.05; 7.8.05 – 11.8.05 – 15.8.05 – 21.8.05 – 25.8.05 – 30.8.05 – 3.9.05 – 10.9.05 – 15.9.05 – 21.9.05. It also appears from the record that there are now two pressure sores but no assessments or plans to guide staff in their care. There are no photographs to illustrate the wounds and no dimensions recorded in order to measure progress or deterioration. There was no plan as to how other skin integrity should be maintained. The “social needs” care plan for this individual referred only to how staff should deal with her verbal and physical aggression. The third care plan scrutinised related to a service user who is PEG fed. This care plan had been reviewed monthly and a catheter care plan was in place which was also reviewed monthly. Although there was a risk assessment for pressure sore development dated 3 November 2005 which referred to turning and use of a pressure relieving mattress there was nothing specific regarding what was described by a senior carer as a “sore bottom” and the advice of the Tissue Viability nurse given on that date had not been translated into a care plan. A recent event investigated as part of the adult protection process was triggered by a resident’s family members observing bruising on their relatives’ legs. It could not be fully established how these bruises had occurred. Scrutiny of this resident’s care records showed that staff had completed charts since March 2005 describing bruises that had been observed on this resident but there was little information to describe actions or interventions undertaken by staff to investigate the reasons for the bruising. Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not inspected on this occasion. Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully inspected, although some conclusions about healthcare are reported under Section 2. It was also noted that none of the files examined contained any indication that the service users’ wishes concerning terminal care and death had been discussed. Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not inspected on this occasion. Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 29 and 30 The home does not have a programme of refurbishment; this has lead to parts of the home, particularly the en suite facilities and bathrooms, to require prompt action by the registered person to ensure that they are safe and pleasant to use. Infection control practices and procedures within the home are not robust and therefore place residents and staff at potential risk of healthcare acquired infections. Hot water temperatures are not adequately controlled by the home, therefore putting residents at risk of harm. EVIDENCE: The inspection in July 2005 identified that a recent refurbishment programme had improved the internal appearance of the home and a selection of bedrooms that were observed had been redecorated. On the day of this inspection observations made of a selection of bedrooms confirmed that residents and/or their representatives are able to bring in Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 15 possessions from home such as pictures, photographs and ornaments to personalise their bedrooms. However the décor appeared “tired” with paintwork and plaster chipped in areas. Bed linen was observed to be minimal and of poor quality. Flooring in some of the en-suite bathrooms appeared stained and in parts peeling away from the floor, wall tiles were observed to have some mould growth. Floor covering in a selection of communal bathrooms and toilets was also stained. The markings on the tops of taps to indicate whether the tap was hot or cold were missing from some of the wash hand basins in communal toilets and bathrooms (this deficit had previously been identified in en-suite facilities in July 2005). A visit to the home on 28th September 2005 had identified that in two bedrooms the temperatures of hot water at wash hand basins exceeded 50 degrees centigrade. Written and verbal confirmation has been received by CSCI from the operations manager to confirm that all faulty valves have been replaced. However at this inspection hot water temperatures continued to fluctuate from various hot water outlets within the home. For example the temperature of the hot water outlet at the wash hand basin in the communal bathroom on Blue wing was recorded by the inspector at 30 degrees and in Room 10 on Yellow Wing the temperature was recorded at 56 degrees centigrade. This was brought to the attention of the operations manager who confirmed that prompt action would be taken to address this. However, given that this problem has not been adequately addressed despite requirements made in the past, the home is urgently required to develop a system where deviance from the required temperature range is identified and dealt with to ensure service user safety. Wardrobes in residents bedrooms were free standing and although robust were observed not to be secured to the wall. The registered person is strongly advised to assess each bedroom to ensure that there is no risk of wardrobes falling over should a resident pull on them. A patio door from one residents room was marked with a notice “do not use-hinges broken”, the resident and visiting relative reported that this sign has been in place for approximately eight months and the door is still awaiting repair. Disability equipment was seen around the home and the acting manager confirmed that equipment is provided on an individual basis following assessment of the resident by a suitably qualified person. The home has extremely limited provision for the storage of aids and equipment with most equipment being stored in the lounge areas within each unit on the ground floor. Although this does not restrict movement around the home for residents or staff, visually it gives the appearance that the environment is cluttered. The sensory room was observed to contain walking aids and other physiotherapy equipment. Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 16 One shower room on Yellow Unit is currently being used for storage of domestic trolleys, a bathroom on Blue wing was being used to store clean linen as well as a “dirty linen trolley” and another shower room also had clean linen stored inside. A new sluice disinfector has been fitted into a small room on one unit. As the bed- pan macerators on the other units have not been repaired or replaced, the new disinfector serves the whole home, which is not sufficient. The operations manager has recently confirmed in writing that the faulty bedpan macerators are waiting for repairs to be completed (previously identified for action in December 2004). Disposal bins without lids were observed in several parts of the home. A programme of routine maintenance and renewal of the fabric and decoration of the premises was not available for inspection. It was discussed with the operations manager and acting manager to conduct an audit of all areas of the home so as to devise a programme of refurbishment and maintenance for the whole home which the home can then keep under review. On arrival at the home the inspectors found the main reception area unattended and the inspectors were able to walk into the home without notice and without staff requesting identification. Residents continue to have unrestricted access around the home and grounds. Following the inspection in July 2005 the home confirmed that resident whereabouts are closely monitored, however incidents reported to CSCI since the July inspection suggest that this is not always the case. Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 and 35 Recruitment practices are poor with appropriate checks not being carried out with the potential to put service users at risk. Staffing levels are insufficient, leading to service users’ needs not always being met. There is a lack of evidence that staff are competent to meet service users’ support needs, again leading to the potential for service users to be placed at risk. EVIDENCE: Feedback received from four relatives at the inspection in July 2005 had indicated that staffing levels were not sufficient and the home was required to keep staffing levels under review. At this inspection two residents and one relative felt that staffing levels are not sufficient within the home. One resident was disappointed that she had not been assisted to wash and dress until 11.30 am and another resident also spoke of frequent occasions when he is not washed and assisted to get up until late morning. Both of these residents spoke of numerous occasions when staff have come to assist them but have been called away to assist elsewhere. One commented that “staffing levels were good two years ago but now there is not enough staff”. Healthcare professionals visiting the home have also reported to CSCI that call bells are not answered quickly enough, a concern previously Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 18 identified by relatives. Lounge areas continue to be left unsupervised for long periods of time. Given the dependency levels of the people accommodated at this home, and their specialist needs, it is considered that having two qualified staff on duty is insufficient. It has been noted that just conducting the medication round can occupy one nurse for several hours. The home is required to review staffing levels and to increase the number of nurses available during the day. The file for a senior carer was examined, as this person was on duty on the day of this inspection and was helpful in volunteering information about care of service users and the running of the unit. Although it was evident that this individual is experienced in care, the record of recruitment and induction to the home fell well short of expectations. Appointed as Senior Care from 16 September 2005, a CRB disclosure was not obtained until 3 November 2005. There was no evidence of a POVA 1st check being obtained. A copy of the top part of an old CRB dated May 2002 conducted by a previous employer was on file but did not show any information about convictions. Two appropriate sources of references are given on the application but neither has been acquired by the home. One reference, from someone not named on the application and whose connection with the employee is unclear (stated as “external agency liaison” on the form) was on file. There was no photograph and no record on file of orientation to the home, induction or training provision since employment at Wrottesley. Although this worker spoke confidently about hoisting residents, and stated that senior staff were allowed to do dressings when a nurse had checked their competence, there was no record of him having been approved as competent to either use hoists or administer dressings. The last manual handling training certificate on file was dated 2001. The lack of evidence regarding this person’s suitability for employment and competence to carry out care tasks are considered serious failures and the home must ensure that procedures to promote service users’ safety are adopted as a matter of urgency. Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42 The home is not currently well run, and there are significant challenges for the new manager and the operations manager to address in order to improve this situation. The health, safety and welfare of service users is not currently being promoted adequately, placing service users at risk. EVIDENCE: The home continues to operate without a registered manager although the previous deputy manager has now taken on the lead role. Given the length of time that the home has operated without a registered manager an application for the new person in charge is required urgently in order for her “fitness” to be assessed. The home has acquired a whole new range of policies and procedures to assist the manager in ensuring that staff conduct themselves appropriately. Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 20 A large number of fire doors within the home have recently been replaced. During a tour of the ground floor of the home, one bedroom door was seen to be held open by a door wedge and another bedroom door was wedged open by a wheelchair footplate. The wedging open of doors is an unacceptable practice and if residents dislike having their doors closed then a self-closing device linked to the fire alarm system must be fitted. The door to the new sluice room is difficult to open and close, even with two hands available, and it was observed that there was no smoke detector present in the area containing the sluice disinfector. The registered person must consult with the local fire officer regarding the fitting of a suitable detector in this room and seek advice regarding the appropriate self-closing devices for bedroom doors. Following the inspection in July 2005 the home provided written confirmation that staff involved in the fitting of bed rails had received appropriate training and that the maintenance of bed rails is incorporated into a maintenance programme. The maintenance person has commenced regular checking of bed rails and showed the records to confirm this. However he also confirmed that he has not receiving training and has not been given the relevant guidance regarding the “Safe Use of Bed Rails” that was previously given to the home by CSCI for distribution to staff. The importance of being aware of the relevant guidance was discussed with the maintenance person and a further copy of the relevant guidance was given to the home. A waste bin for the purpose of disposing of clinical waste was observed to be unlocked and overflowing and this was brought to the attention of the operations manager for action. Although information provided by the home suggests that staff have received moving and handling training, the content of the training provision is questionable, apparently being reliant on watching a video rather than being given “hands on” training and assessment. For the newly appointed worker whose file is described earlier in this report, there was no record of having had moving and handling training (other than a certificate gained while with a previous employer dated 2001) or having been assessed as competent in the use of the hoists, which he clearly was using on a regular basis. The registered person must ensure that staff receive up to date moving and handling training. It was discussed with the operations manager and acting manager that this training should incorporate practical elements so that staff are trained and assessed as competent in the use of all moving and handling equipment needed to assist residents. There was no evidence of training or guidance being provided for staff on the use of the sluice disinfector. The home is now reporting accidents and incidents to CSCI although discussion with the operations manager and acting manager confirmed that these have Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 21 not been audited as requested following the inspection in July 2005, despite written confirmation stating that auditing had been implemented. Wrottesley Park House Nursing Home DS0000036983.V267282.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 Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 1 2 x x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 x x x X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 2 2 x 2 1 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score x x 2 1 1 x CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x x x Standard No 37 38 39 40 41 42 43 Score 1 x x x x 1 x Wrottesley Park House Nursing Home DS0000036983.V267282.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 YA1 Regulation 4 Requirement Timescale for action 13/01/06 2 YA2 14 3 YA2 14 4 YA3 14 The registered person must complete the statement of purpose for the home, ensuring that it is an accurate reflection of the service actually available Full assessments of each service 15/12/06 user must be conducted prior to admission, which must take into account specific condition related needs, specialist needs and management of risk and revised at any time when necessary to do so The registered person must 13/01/06 confirm in writing to the service user that the care home is suitable for the purpose of meeting their needs The registered person must not 15/12/05 admit people whose needs it cannot meet The registered person must ensure that all assessments and care plans are accurate and do not include inconsistent and conflicting information (Previous timescale of 21/07/04 not met) 15/12/05 5 YA6 15 (1) Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 24 6 YA24 7 YA24 8 YA26 9 YA27 10 YA29 11 YA30 12 YA30 13 YA30 A programme of routine maintenance and renewal of the fabric and decoration of the premises must be produced, implemented and records kept 13 (4) (c) The registered person must establish a safe and secure entrance to the home and establish a system of monitoring which residents are in the building (Previous timescale of 1/10/05 not met) 16 (2) (c) The replacement of faulty and stained bed linen must be incorporated into the maintenance and renewal programme. The registered person must ensure that bed linen is sufficient and appropriate for each resident 12(1-a,b) The floor covering in shower 23(2-d) rooms, ensuite facilities, communal bathrooms and showers must be cleaned and/or replaced, and the wall tiles attended to where necessary 23 (1) The provision for storage of aids and equipment must be reviewed. Bathrooms must not be used for storage 13 (3), (4) Taps in service users’ bedrooms (c) must indicate which is hot and cold (Previous timescale of 1/10/05 not met) 13 (3) The registered person must ensure that the bedpan macerators are either repaired or replaced (one sluice disinfector now fitted). Compliance with previous immediate requirement not fully met 13 (3) Waste disposal bins must be appropriate for their use and fitted with lids. Clinical waste must be stored securely 23-2,d 5, 16-2,j 13/01/06 13/01/06 13/01/06 28/02/06 13/01/06 13/01/06 28/02/06 13/01/06 Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 25 14 YA33 18 (1) (a) 15 YA33 18 (1) (a) 16 YA34 19 (4) 17 YA34 19 (4) 18 YA35 18 (1) (c) 19 YA35 18 (1) (c) 20 21 YA37 YA42 8 23 (4) The registered person must review staffing levels regularly to reflect service users’ changing needs The registered person must deploy an additional nurse to ensure that the clinical and health needs of service users are fully met The registered person must obtain two written references before allowing a person to work at the care home (Previous timescales of 15.7.04 and 1.9.05 not met) The registered person must not allow someone to work at the home without obtaining a POVAL/CRB disclosure The registered person must ensure that all staff are provided with appropriate induction training (Previous timescale of 21.7.04 not met) The registered person must ensure that all staff receive training appropriate to the work they are to perform, and create a training and development plan to demonstrate this, linked to service users’ needs An application to register the acting manager must be submitted The registered person must consult with the local fire officer regarding the fitting of a suitable detector in the new sluice room The registered person must consult with the local fire officer regarding the fitting of appropriate self-closing devices for bedroom doors. The practice of using door wedges must cease 13/01/06 15/12/05 15/12/05 15/12/05 15/12/05 13/01/06 15/12/05 13/01/06 22 YA42 23 (4) 13/01/06 Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 26 23 YA42 24 YA42 18(1)(c)(i) The registered person must 15/12/05 ensure that staff involved in the fitting of bed rails receive appropriate training (Previous timescale of 1.9.05 not met) 13(4)(c) The registered person must 15/12/05 ensure that hot water outlet temperatures are maintained as close to 43°C so as to minimise the risk of scalding (Previous timescale of 1.10.05 not met) 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 Wrottesley Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE 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 Park House Nursing Home DS0000036983.V267282.R01.S.doc Version 5.0 Page 28 - 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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