Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 16/12/05 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 16th December 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 38 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

There was nothing apparent to inspectors during this visit, or stated by service users or visitors, to provide evidence of anything being done well at present at this home. Some service users and visitors did say that some of the staff were approachable and committed to their work, but also identified that this was not the case overall.

What has improved since the last inspection?

New formats have been purchased in order to improve systems such as care planning. However, inspectors found that the actual content entered in these formats had not particularly improved which leads to the conclusion that it is the skills and value base of staff undertaking the tasks and completing the documentation which is lacking, not the documentation itself.

CARE HOME ADULTS 18-65 Wrottesley Park House Nursing Home Wergs Road Tettenhall Wolverhampton West Midlands WV6 9BN Lead Inspector Ros Dennis Unannounced Inspection 16th December 2005 10:00 Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 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.V275795.R01.S.doc Version 5.1 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.V275795.R01.S.doc Version 5.1 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.V275795.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: Wrottesley Park 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. The home is located on the main A41 Albrighton/Telford road out of Wolverhampton on the Wergs Road, half a mile past Tettenhall Village Green. The home is purpose built with three residential areas on the ground floor, each having fifteen single bedrooms and communal areas. The first floor has twelve bedrooms and people accommodated here access communal space on the ground floor. 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 bedrooms within the property, however these six bedrooms have not yet been registered for use by CSCI. Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over the whole of one day, a Friday, with briefer visits being made to follow up on individual issues on the following Monday. Four inspectors conducted the bulk of the inspection work, focusing on individual areas but cross referencing their conclusions where appropriate to build a picture of how the home is functioning. The purpose of the inspection was to monitor progress relating to requirements made following an announced inspection in November 2005, following which assurances were made by the provider that issues were being addressed and shortfalls rectified. Although inspectors acknowledge that a range of policies, procedures and formats have been purchased and some staffing resources were allocated short-term by the provider to remedy problems, there is little evidence of improvements and no evidence that the quality of life experienced by service users at the home has improved. Some significant concerns identified in earlier inspections were found not to have been addressed, including unsafe hot water temperatures, inadequate staff recruitment, failure to ensure the safety of bed rail provision and the continued failure of care records to reflect the needs and aspirations of service users accommodated at the home. Four statutory notices requiring the home to comply with the regulations relating to these issues were served on 28 December 2005, which specify exactly how the home has failed and what must happen to bring the home in line with the legislation. What the service does well: What has improved since the last inspection? New formats have been purchased in order to improve systems such as care planning. However, inspectors found that the actual content entered in these formats had not particularly improved which leads to the conclusion that it is the skills and value base of staff undertaking the tasks and completing the documentation which is lacking, not the documentation itself. Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 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.V275795.R01.S.doc Version 5.1 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.V275795.R01.S.doc Version 5.1 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): 2 and 3 Individuals have been admitted to the home without their individual needs and aspirations being assessed. This has put the safety and wellbeing of those people admitted and people already living at the home at risk The home is currently unable to meet the needs of people living there. There is a great diversity of need presented by the current service user group and a lack of specialist knowledge, skills and services to deliver appropriate support. There is an outstanding requirement from the November 2005 inspection relating to the completion of the statement of purpose (timescale 13.1.06) which was not re-assessed on this occasion EVIDENCE: The home has admitted people with a wide range of needs, some outside its registered categories, which has lead to the current group of service users who present a wide range of disabilities/difficulties in addition to having either a learning or physical disability – for instance, mental health problems, behaviour which challenges, sensory impairment, acquired brain injury, alcohol abuse, epilepsy. These are in addition to a similarly wide range of medical needs presented by health problems such as diabetes, strokes, Parkinsons, hypertension, hepatitis, obesity, angina, renal failure. In terms of very basic skills, staff do not have the ability to communicate effectively with service users and no communication aids or adaptations appear to have been made Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 9 available. There is no evidence of the staff group having, individually or collectively, the skills and experience to deliver appropriate, specialist, services. The records for four service users were looked at in depth to establish how the home ensures that they can care for the people they admit. Two of these records were for people admitted in October and November of this year. The records seen for these people demonstrated that the home had not fully assessed their needs prior to admission. In terms of one particular individual, whose presence in the home has placed people living and working there at risk, vital information provided by the placing authority had not been fully explored or used to establish an effective care plan. The written records seen showed that there was insufficient detail to guide staff as to how to safely care for that person, themselves or other service users. There was no information to show that the person themselves or a representative had been involved in the admission process. Several residents expressed their concern and dissatisfaction about the “newer” types of resident being admitted to the home and stated that people were staying in their own rooms more due to the disruptive behaviour seen in the communal areas. Residents commented on the aggressive bad language witnessed and said that they no longer enjoyed eating in the dining room due to the “fighting and noise” that goes on. Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 10 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 planning processes do not provide an accurate reflection of service users’ needs, have significant omissions and contradictions which place people at risk and show no evidence of having been agreed with service users EVIDENCE: It is acknowledged that the home has made recent efforts to update its care plans with a trained nurse having concentrated on this work for some three weeks. It appears from comments made by residents that this work had not been used as an opportunity to involve them in the care planning process. Significant shortfalls are still apparent. Fourteen care plans were examined during the course of this inspection. Shortfalls were identified in all the documentation. Four plans were inspected primarily to measure the “Lifestyle” standards and these were found to lack information relating to appropriate stimulation or activities, opportunities for social inclusion or methods of communication. There was no activities care plan for a service user funded for 12 hours/day one to one support. Deficits identified in other care plans reflect concerns from previous inspections – that care plans are not holistic, are lacking in essential detail in order to Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 11 promote residents’ well being and safety, and do not reflect the specialist requirements of the service user group. Examples are: o No care plan specific to the management of a significant infection posing risks to service users and staff o Inadequate care plan relating to the management of aggressive behaviour for a service user who has assaulted another service user and poses significant risks as identified through history o No nutritional care plan for someone who is clearly underweight and visibly emaciated o Lack of care plans relating to promotion of skin integrity for people at risk o Lack of reactive care plan in case of hypoglycaemic events for person with diabetes o Absence of care plans for specialist needs such as low potassium diet, sleep apnoea o Lack of transfer of essential placing authority information into care plan and contradiction of safety measures in that service user said to be at risk of eating incontinence pads being provided with them at the home o Failure to provide a management plan for follow up care for a surgical excision wound which lead to lack of appropriate care, delay in removal of sutures, inflammation and infection o No behaviour care plan for someone identified as schizophrenic and having unpredictable mood changes o No pre-admission assessment or care plan for someone recently admitted to the home o Lack of improvement to care plan identified as inadequate in November 2005 One service user interviewed who had lived at the home for 6 months was not aware of the home’s responsibility to develop his care plan with him. This person was articulate and very able to express his views and it was apparent that he had not been involved in making decisions or choices about his lifestyle, which had had a negative impact on his quality of life at the home. Another service user confirmed that their care plan stated that the individual should have one to one time for several hours per week, this had not been achieved and it was estimated that the person only received half the agreed quality time as outlined in the care plan. Given the home’s continued failure to provide adequate care plans and associated documentation, a statutory notice under Regulation 43 of the Care Homes Regulations 2001 was served following this inspection requiring that the home comply with Regulations 15 and 17. Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 12 Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 13 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): 11,12,13,14,15 and 16 Service users are not provided with opportunities to lead a positive lifestyle EVIDENCE: Through discussions with service users, examination of care records and observation throughout the day of inspection, it was established that there are no opportunities for life skills development at the home. Staff lack the basic skills for communication with some service users and there are no specialist aids available. Although there is a part-time activities organiser and a physio assistant, they are not trained to work with specialist needs presented by the client group. Assessments and care plans lack the information and direction necessary to form the basis for staff to enable service users to maintain or develop social, emotional, communication or independent living skills, nor do staff appear to have the time. One recently admitted service user commented that he had never been asked about his interests. Service users lack stimulation and many are left wandering about the home or sat in front of the TV for long periods of time. A number of service users access local day service provision throughout the week and it was reported that three residents attend Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 14 Headway, a service for people with acquired brain injury. There are no other measures to promote social inclusion and one service user stated that he is prevented from going out due to lack of staff resources. One service user commented “I’m bored out of my skull here day in, day out”. On the day of inspection, a carol service took place in the morning and a small number of service users were taken out to a pantomime in the afternoon. A local church visits the home monthly. There was no evidence of recent holidays having been undertaken in the four case files examined. Visitors were seen to come and go during the inspection. A notice in reception states that there are no restrictions on visiting, and there is a visitors’ book in main reception. Families of service users had been invited to come to the Christmas sing-along. For many of the service users, more could be done to assist them in maintaining contact and relationships with their families and/or friends. Care plans did include the promotion of dignity and privacy but observations showed that the approach of some staff could be improved, particularly in interacting and communicating with service users and giving appropriate assistance with personal tasks. One service user spoken with said that he would like a key to his room but hadn’t been offered one. Preferred forms of address were included in the records seen. Smoking is permitted in designated areas. The provision of meals and nutrition was not inspected in full on this occasion. However, during the morning of the inspection, a member of care staff was observed to commence an enteral feed for a service user whose records had been examined. This resident’s care plan regarding enteral feeding requests the reader to observe a separate folder for information on types of PEG feeds and specific feed regime. Observation of this folder shows that the type of feed that had earlier been commenced was a different feed type to the one recorded on this individual’s feed regime. The feed was disconnected approximately four hours later and observations of the feed regime show that the member of staff had not recorded any information on the feed regime chart. The feed had been put up and disconnected by a member of care staff, who was observed not to wash her hands on both occasions. The competence of this carer is questionable as discussions with the acting manager could not confirm whether this member of staff had received any additional training to deem her competent in this field. Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 15 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): 18 & 19 Service users’ physical and emotional health needs are not being adequately addressed, and individual choices and preferences with regard to their personal support are not fully respected. EVIDENCE: Although there are some efforts to ensure that personal support is delivered sensitively – notices on doors saying “Please knock before entering my room”, there are also inappropriate practices such as bath and shower “lists” on display and information on bedroom doors relating to the incontinence products used by individuals. Records seen indicate that some service users start getting ready for bed at 6.00pm – one service user stated “I go to bed when I get put into bed” and added that he had a shower if the shower was working and if staff were available, otherwise staff “throw a sponge over me”. A number of service users were poorly presented with no shoes or slippers and odd socks. One service user stated “I wear what I’m given”. Although the make up of the staff group would enable some gender/ethnic choice there is no evidence that this issue has been explored. Adaptations and equipment are available in the home, but reported as sometimes not readily available for use by individuals at the time they are needed. There is a lack of storage, so equipment tends to be left in communal Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 16 areas or in bathrooms. Service users are still being moved around the home inappropriately for instance without foot plates on wheelchairs (for some people this has been risk assessed but not for all those this applies to), and two were seen been moved backwards in Kirton posture chairs – an inappropriate use of the chairs and disorientating to people being moved, highlighting again the need for moving and handling training. The home’s sensory room is in need of redecoration and repair. It was reported by staff that there is a key worker system whereby an allocated member of staff spends 1-2 hours per month with “their” individual service users. However, the system is under review and the home is exploring the use of keyworker books to be maintained in each service user’s bedroom. Evidence relating to the healthcare needs of service users is also contained within standard 6 above, in terms of planning to meet those needs. Inadequacies in planning are reflected in identified inadequacies in care delivery, as observed directly and through examination of records. Shortfalls identified in administering someone’s PEG feed are described under standard 17. One resident whose file was examined did have a care plan relating to wound care. However, discussions with staff and records of the care provided did not comply with the plan. One of the wounds was to be dressed daily but entries in the records showed that it had been dressed on only 3 occasions out of a potential of 8, having been dressed only on 9.12.05; 12.12.05 and 16.1205 instead of daily. As referred to in standard 6, another wound was not cared for appropriately. This was from a breast lump excision on 21.11.05. Mepore dressings were left in the room. There are no records of checks being made on this wound until 25.11.05 when “dressings renewed – wound healthy” is recorded. There is no other mention of this wound until 1.12.05 when it is documented that the person has inflamed stitches. The hospital was contacted for advice and it is documented that the home can remove them. An entry on 2.12.05 details “needs sutures removing – need to get a suture removal pack from GP”. There is then a delay of 5 days before this resident attends his GP surgery for removal of some of his sutures and is subsequently commenced on antibiotic therapy. The resident then returned to the GP for removal of remaining sutures on 9.12.05. There is no other mention of his suture line being checked and no wound care plan at any stage. The November 2005 report referred to an event that was investigated as part of the adult protection process, triggered after family members observed bruising on their relative’s legs. Another event that has occurred since the November 2005 inspection was also investigated as part of the adult protection process. This again related to someone admitted to Wrottesley Park for a Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 17 period of respite who returned to their home with bruising to their back and arm. Although this individual’s care file contained a Waterlow assessment, there is no record of this person’s skin being observed by a member of staff. It therefore cannot be established how these bruises occurred. Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 18 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.V275795.R01.S.doc Version 5.1 Page 19 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): 30 Policies and procedures are not in place or being followed to ensure good hygiene practice EVIDENCE: This standard was not inspected in full. However, during the morning of the inspection, a member of care staff was observed to commence an enteral feed for a service user whose records had been examined. The feed had been put up and disconnected by a member of care staff, who was observed not to wash her hands on both occasions. The competence of this carer is questionable as discussions with the acting manager could not confirm whether this member of staff had received any additional training to deem her competent in this field. Further observations made during the inspection provided further evidence that staff are not aware of good practice regarding infection control, such as the correct disposal of soiled linen, de-scaling of showers and cleaning of clinical equipment. The acting manager confirmed that staff have not received infection control training. Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 20 The home still only has one functioning sluice disinfector despite requirements being made to either repair or replace bedpan macerators in other parts of the home (originally identified for action in December 2004). There was no specific care plan for a service user diagnosed as having a specific infection, alongside a range of other health and behavioural problems, which could place staff and other service users at risk. Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 21 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): 32, 33, 34 & 35 Staffing levels and the collective skills, experience, training and support of the staff group are insufficient to meet the needs of the service users accommodated at this home EVIDENCE: It is clear from comments from visitors and service users that some staff are committed to their role and to the welfare of the residents. However, it is also evident that the competencies and qualities of some do not reach required standards, being unapproachable, poor communicators (or unskilled in using the means of communication required) and apparently indifferent to some of the service users’ needs. Although some training in awareness of the needs of people with learning disabilities has been provided, staff collectively and individually do not have the skills and experience necessary to deal with the disabilities and specific conditions of service users. The home does not have sufficient numbers of staff to support the service user group. Although the home’s senior management have assured CSCI that service users are constantly supervised, this was observed not to be the case throughout this inspection. Service users were observed to be left for considerable amounts of time (4 hours being one example) without any attention, and Yellow unit was left unsupervised with seven residents present at one point during the day. Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 22 Throughout the morning, call bells were heard to be ringing continuously much to the irritation and frustration of other residents observed in the lounge area. In one instance, a call bell was heard to be ringing continuously for over fifteen minutes. When the carer attended to turn it off, she assured the service user that she would be “back in a minute”, but another ten minutes passed before another carer attended this individual. On examination of the accident book, it was identified that this service user had experienced many falls in recent weeks – therefore it would be expected that calls from this source would have been regarded as a priority. A service user commented that the care staff were “too busy to make genuine conversation and take an interest”. One service user said “I wait all day”. As reported earlier, there are few opportunities for staff to promote service users’ social or leisure interests. Some staff commented that the team are unmotivated and uncommitted and “can’t be bothered” to interact with service users. Concerns relating to lack of training, and particularly induction for new staff, have been documented in previous reports and assurances given by the company that staff do receive induction. At this inspection, a qualified member of staff was seen conducting the medication administration at the home. This was her third day working at the home, there was no record of induction or competence and this person stated that she had been “shown round the unit” indicating a lack of formal induction provision. Given the home’s continued failure to provide adequate induction for new staff, a statutory notice under Regulation 43 of the Care Homes Regulations 2001 was served following this inspection requiring that the home comply with Regulation 18 (1). The file for a new recruit to the home was checked for compliance with Schedule 2. A POVA first check was present, as were references and the only failure to meet recruitment requirements was a lack of photograph. The home’s acting manager has audited personnel files and identified the deficits against the regulations and is taking action to remedy the shortfalls. This will be monitored at further inspections. Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 23 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): 42 This home does not promote the health, safety and welfare of residents and is currently placing residents at significant risk of harm. EVIDENCE: The inspectors chose to access the first floor of the home via a staircase and on nearing the top of the stairs found a wheelchair-dependant resident attempting to gain access to the staircase. This resident had already managed to open one fire door and was attempting to open the second door, which would have taken her to a point directly at the top of the stairs. The resident was assisted back onto the main corridors by the inspectors, a member of staff was found and informed of the incident and that the resident wanted to go to the ground floor. The staff member directed the resident towards the lift stating “its this way” to which the resident responded, “I didn’t know I’m confused”. Clearly the resident was able to access the top of the staircase unknown to staff, and the fire doors are not alarmed or fitted with an appropriate device to prevent resident access. Following previous concerns about staffing levels and Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 24 the lack of supervision of vulnerable service users, highlighted particularly in the inspection report from July 2005, the home confirmed that residents’ whereabouts are closely monitored and in October 2005 the managing director also confirmed that “residents are supervised at all times”. This serious near miss incident and other recent incidents reported to CSCI suggest that the level of staff supervision within the home is not sufficient to ensure the safety and well being of residents. During visits to the home in September and November 2005 CSCI inspectors monitored hot water temperatures at varying outlets accessible to residents. Temperatures have exceeded 43°C and following the inspection in November 2005 the home was urgently required to devise a system where deviance from the required temperature range for hot water is identified and dealt with to ensure service user safety. At this inspection ten out of twenty five hot water temperatures checked from varying outlets such as baths, showers and wash hand basins were recorded at more than 44°C, four of these outlets had temperatures of between 51.6°C and 67°C. An immediate requirement was issued at the time of inspection for emergency signage to be put in place and for the hot water supply to be turned off in the rooms affected. Close observation of bathrooms and en-suites confirmed that they were in need of urgent refurbishment. In nine of the en-suites (Yellow Wing rooms 3,5,7,9,12; Blue Wing rooms 7,10,12 & 14) tiles at ankle height were found damaged and chipped and these were notably sharp to the touch thus potentially could cause injury to residents. This was brought to the attention of the maintenance person for prompt remedial action to be taken for the interim period until these tiles are replaced. A kettle is available in Yellow unit for residents/visitors to make themselves a drink, however the inspectors were concerned that this “tea-bar” is not directly supervised by staff, the kettle is at hip height and one resident that was observed to attempt to make herself a cup of coffee in yellow unit had significant jerky movements of her arms. This resident was later observed to drop a cup of coffee on the floor. Although it is not wished to take independence away from residents the home must reconsider the placing of this facility so that it can be closely supervised by staff. Hard flooring surrounding the tea bar and dining area on Yellow Unit is not anti-slip, and several staff members were observed to slip on this flooring during the inspection. During the inspection numerous free-standing Halogen heaters were seen in residents rooms and communal rooms. Whilst one inspector was in the communal lounge on Yellow Unit one member of staff was heard to inform a client not to get too close to the heater, this client was then left unsupervised for a considerable length of time with the heater still on. Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 25 It was observed during a tour of the home that one person slept on a mattress on the floor. The records for this person lacked information to show how this could be managed safely. There were no specific guidelines to ensure staff knew how to lower and raise her from floor level. Although some padding was seen in place along the top of the mattress, along two walls there was no protection for the service user and no indication that consideration had been given to preventing the person sustaining any impact injury from this. It was stated that the person is nursed on the mattress on the floor to minimise injury, but some potential hazards had not been considered, assessed or minimised. A random selection of 11 rooms contained beds with bed rails attached, of these only two pairs were found to be fitted correctly and in accordance with the relevant Medical Devices Agency and Health and Safety Executive guidance. Two bed rails were found to be faulty as the mechanism to secure them to the bed was missing (Room 8,Yellow Unit and Room 14 Blue Unit), another bed had two different types of bed rails fitted and 8 beds were observed to have pressure relieving mattresses on top of an ordinary mattress. As the bed rails were only of a 3 bar design, the additional height of the overlay mattress compromises the effectiveness of the bed rail. The inspector was particularly concerned that the additional height of a pressure sore overlay system was placing a resident observed in bed on Brown Unit at considerable risk of rolling over the top of the 3 bar bed rail. This bed was also positioned next to a wall and only had one side of a pair of bed rails in place. The acting manager was requested to initiate urgent action in order to safeguard this resident. A visit later that day by CSCI confirmed that this action had been taken. The inspector observed that the home had taken delivery of several new sets of 3 bar bed-rails and it was discussed with the acting manager that the home must also consider purchasing extra height bed rails if pressure relieving mattresses or overlays are to be used. Methods to be deployed for the interim period were discussed with the acting manager, such as removing the ordinary mattress and securing the pressure-relieving mattress to the base of the bed. Documentary evidence was available to confirm that a company that manufactures bed rails had recently provided training in the fitting of bed rails; the acting manager confirmed that 22 members of staff had attended this training. Although the content of this training was not checked, observations made at this inspection confirm that staff are still not clear on the correct procedure to be employed regarding the fitting of bed rails in order to maintain resident safety and reduce the risk of injury. Given the home’s continued failure to ensure the safety of service users particularly in the areas of access to hot water and the provision of bed rails, statutory notices under Regulation 43 of the Care Homes Regulations 2001 were served following this inspection requiring that the home comply with Regulations 13 and 23. Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 26 The home’s acting manager has not yet submitted application to CSCI for registration, despite an assurance given at a meeting held with the provider and acting manager on 22 November 2005 that this would be undertaken within two weeks. Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 27 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 Standard No Score 1 X 2 1 3 1 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 1 33 1 34 2 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 X X X X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 1 15 2 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 1 X X X X X X X 1 X Wrottesley Park House Nursing Home DS0000036983.V275795.R01.S.doc Version 5.1 Page 28 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4 Requirement The registered person must complete the statement of purpose for the home, ensuring that it is an accurate reflection of the service actually available (not assessed at this inspection) New service users must only be admitted on the basis of a full assessment which concludes that their needs can be met by the home Full assessments of each service 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 (previous timescale of 15/12/05 not met) Timescale for action 13/01/06 2 YA2 14 20/01/06 3 YA2 14 20/01/06 4 YA2 14 The registered person must confirm in writing to the service user that the care home is suitable for the purpose of meeting their needs (timescale from November 2005 report) 13/01/06 5 YA3 14 The registered person must not DS0000036983.V275795.R01.S.doc 13/01/06 Page 29 Wrottesley Park House Nursing Home Version 5.1 admit people whose needs it cannot meet or with whom it cannot develop effective communication (ongoing requirement with which the home must demonstrate compliance) 6 YA11 7 YA12 8 YA13 9 YA14 10 YA15 11 YA16 12 YA18 13 YA18 14 15 YA18 YA18 16(2)(m)(n) The registered provider must provide opportunities for service users to learn and use practical life skills 12(1) The registered provider must enable service users to take part in age, peer and culturally appropriate activities 12(1) The registered provider must enable service users to be come part of, and participate in, the local community 16(2)(n) The registered person must ensure that service users have access to a range of appropriate leisure activities 16(2)(m) The registered person must support service users to maintain family links and friendships 12(1)(b) The registered person must ensure that daily routines of the home promote choice and independence 12(1)(b) The registered person must ensure that service users’ preferences with regard to their care are identified and respected 12(1)(b) The registered person must ensure that service users can choose their own clothes, hairstyle and makeup 12(1)(b) Service users must be provided with the technical aids and assistance required 12(1)(b) The registered person must ensure that consistency is provided through key working (with the involvement and choice of service users) DS0000036983.V275795.R01.S.doc 24/03/06 24/03/06 24/03/06 24/03/06 24/03/06 24/02/06 27/01/06 27/01/06 27/01/06 24/02/06 Wrottesley Park House Nursing Home Version 5.1 Page 30 16 YA24 23(2)(d),5, 16(2)(j) A programme of routine maintenance and renewal of the fabric and decoration of the building must be produced, implemented and records kept (timescale from November 2005 report) 13/01/06 17 YA24 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 (timescale from November 2005 report – previous timescale of 1/10/05 not met) 13/01/06 18 YA26 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 13/01/06 (timescale from November 2005 report – standard not re-assessed at this inspection) 19 YA27 12(1)(a,b) 23(2)(d) The floor covering in shower rooms, ensuite facilities, communal bathrooms and showers must be cleaned and/or replaced, and the wall tiles attended to where necessary 28/02/06 (timescale from November 2005 report – standard not re-assessed at this inspection) 20 YA29 23(1) The provision for storage of aids and equipment must be reviewed. Bathrooms must not be used for storage 13/01/06 (timescale from November 2005 report – standard not re-assessed at this inspection) 21 YA30 16(2)(j) The registered person must consult with the local infection control specialist to ensure that practices within the home follow current infection control guidelines DS0000036983.V275795.R01.S.doc 24/02/06 Wrottesley Park House Nursing Home Version 5.1 Page 31 22 23 YA30 YA30 16(2)(j) 18(1)(c) 13(3), 4(c) The registered person must 24/03/06 ensure that staff receive infection control training Taps in service users’ bedrooms 13/01/06 must indicate which is hot and cold (previous timescale of 1/10/05 not met) 24 YA30 13(3) Waste disposal bins must be appropriate for their use and fitted with lids. Clinical waste must be stored securely 13/01/06 (timescale from November 2005 report – standard not re-assessed at this inspection) 25 YA32 18(1)(a) 26 YA32 18(1)(a) 27 YA33 18(1)(a) The registered person must ensure that service users are supported by staff competent to undertake the tasks they do The registered person must ensure that staff have the specialist qualifications, skills and experience to support the service user group The registered person must review staffing levels regularly to reflect service users’ changing needs (timescale from November 2005 report) 24/02/06 24/02/06 13/01/06 28 YA33 18(1)(a) The registered person must deploy an additional nurse to ensure that the clinical and health needs of service users are fully met 15/12/05 (timescale from November 2005 report – requirement met for a three week period but then reverted to previous level) 29 YA34 19(4) The registered person must obtain two written references before allowing a person to work at the care home 15/12/05 (previous timescales of 15/7/04 and 1/9/05 not met – this is an ongoing requirement with which the home must demonstrate compliance) 30 YA34 19(4) The registered person must not allow someone to work at the DS0000036983.V275795.R01.S.doc 15/12/05 Wrottesley Park House Nursing Home Version 5.1 Page 32 home without obtaining a POVAL/CRB disclosure (this is an ongoing requirement with which the home must demonstrate compliance but not re-assessed at this inspection) 31 YA35 18(1)(c) 13/01/06 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 (timescale from November 2005 report) 32 YA37 8 An application to register the acting manager must be submitted 20/01/06 (previous timescale of 15/12/05 not met) 33 YA42 23(4) The registered person must 13/01/06 consult with the local fire officer regarding the fitting of a suitable detector in the new sluice room (timescale from November 2005 report) 34 YA42 23(4) The registered person must 13/01/06 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 (timescale from November 2005 report) 35 YA42 13(4)(a) 36 37 YA42 YA42 13(5) 13(4) 38 YA42 13(4) The risk of injury to service users posed by the broken and sharp tiles in en-suite bathrooms must be reduced as a matter of urgency Safe systems for moving and handling service users must be established and adhered to Arrangements for service users to have access to kettles etc must be risk assessed and reviewed Heat sources must be fixed and guarded DS0000036983.V275795.R01.S.doc 27/01/06 27/01/06 27/01/06 27/01/06 Page 33 Wrottesley Park House Nursing Home Version 5.1 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.V275795.R01.S.doc Version 5.1 Page 34 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.V275795.R01.S.doc Version 5.1 Page 35 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!