Inspection on 13/08/07 for Wychwood

This inspection was carried out on 13th August 2007.

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

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

Other inspections for this house

Wychwood 10/11/08

Wychwood 14/05/08

Wychwood 03/01/08

Wychwood 15/11/06

Wychwood 15/09/05

Wychwood 10/05/05

Wychwood 14/02/05

Wychwood 26/10/04

Wychwood 02/03/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Wychwood Headley Road Hindhead Surrey GU26 6TN Lead Inspector Lesley Garrett & Suzanne Magnier Unannounced Inspection 13th August 2007 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wychwood Address Headley Road Hindhead Surrey GU26 6TN 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) 01428 607014 wychgroup@hotmail.com Mrs Mumtaz Minaz Lalani Mrs Mumtaz Minaz Lalani Care Home 24 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (14), Mental disorder, excluding learning of places disability or dementia (1), Old age, not falling within any other category (6), Physical disability (1), Physical disability over 65 years of age (5) Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2006 Brief Description of the Service: The registered home comprises of two separate buildings, which are known as Wychwood, the larger building and Wychdale, which is a bungalow. The proprietor is the registered manager. The service provides 24-hour care and accommodation for up to 24 adults with a varied range of needs. All bedrooms are used as single occupancy, with the exception of three, which may be used as double occupancy. A number have en suite facilities that include a toilet and basin, shower or bath. There are communal lounges and a dining room. The current range of weekly fees are £379.22 - £888.00 Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced ‘Key Inspection’. Mrs L Garrett and Ms S Magnier, Regulation Inspectors, carried out the inspection and a senior care staff member, the deputy manager and subsequently the registered manager represented the service. For the purpose of the report the individuals using the service are referred to as people living in the home. The inspectors arrived at the service at 10.30 and were in the home for seven and a half hours. It was a thorough look at how well the home is doing. It took into account detailed information provided by the home and any information that CSCI has received about the service since the last inspection. The inspectors spent time talking with people living at the home in order to seek their views about the home and the care they receive. No responses to questionnaires that the Commission had sent out had been received prior to the inspection. The inspectors looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Documents sampled during and after the inspection included the home’s Statement of Purpose and Service User Guide, the terms and conditions of residency in the home, care plans, daily records and risk assessments, medication procedures, staff files, a variety of training records, and the home’s safeguarding and complaints policies and procedures. The home had submitted the Annual Quality Assurance Assessment (AQAA) prior to the inspection, some details of which have been added to the report. From the evidence seen by the inspector and comments received, the inspector considers that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. In discussion with the registered manager the inspectors were advised that there had been ongoing consultation with Waverley Council since 2005 regarding the proposals of extending the care home. Several applications have been rejected by Waverley Council and have been subject to appeal by the home’s owners. The inspectors were informed that the current situation is that the building plans have been amended and re submitted to Waverley Council in 2006/2007. The registered manager advised that the home are still awaiting the approval and will seek as a matter of urgency the start date for the Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 6 commencement of building works in order to ensure that the home is fit for purpose. What the service does well: What has improved since the last inspection? What they could do better: A total of twenty-five requirements have been made as a result of this key inspection and can be viewed in detail at the end of this report. The home’s Statement of Purpose and Service User Guide must be updated. Copies must be made available to prospective individuals and people living in the home. Copies of both amended documents must be sent to CSCI local office. The home’s admission and assessment procedures must be improved to ensure that individual’s needs are appropriately identified and met. The care plans must be reviewed and expanded to clearly demonstrate how individual’s needs in respect of health and welfare and are to be met and outcomes for individuals are being achieved. A full review of the current risk assessments be undertaken to ensure that all the hazards in peoples’ daily lives are clearly documented, measures are in place to ensure their safety and well being and reviews are undertaken at appropriate times. The home must also develop a robust system for assessing individual’s nutritional status and actions are in place to record individuals weight gain and loss. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 7 The storage arrangements regarding the medication trolley are to be reviewed in order to ensure the safety of staff whilst handling medication and accurate records must be kept of all medication administered to individuals. The home to contact a care manager for a specific individual to review their care and the person’s entitlements to adequate clothing in order to promote their dignity and respect. The home to supply the Commission with a statement containing a summary of the complaints made during the preceding twelve months and the actions that have been taken in response to any complaints received by the home. The home to obtain the most recent local authority procedures and protocols dated 2005 in order to safeguard vulnerable people in their care. To make arrangements to prevent individuals being harmed, suffering abuse or being placed at risk of harm and abuse and any alleged abuse must be reported to the relevant authorities. Safeguarding vulnerable adults training must be made available to all staff in order to ensure that they are aware of the protocols regarding reporting and detecting abuse in order to safeguard people in their care. The rotting external patio door in an individual’s bedroom is to be repaired or replaced and in the same room appropriate arrangements are made for the destruction of the wasp’s nest. The torn window blind in a communal toilet is replaced in order to ensure dignity and privacy for people using the facility. Bathrooms need to be decorated and assessments made as to the suitability of the baths that are in place due to the growing dependency of the people who use the service. A restraint is to be fitted to the window upstairs in one individual’s bedroom in order to ensure their safety and an assessment to take place of the other windows on the upper floors to ensure they also have restraints. The broken wardrobe structure in an individual’s bedroom is removed and if the structure cannot be moved then it is to be risk assessed in order to minimise any risk to the individual. The lighting in identified areas of the home must be improved in order that individuals have adequate lighting to ensure their safety and comfort. Arrangements must be made to eradicate the malodour in order that the individual’s bedroom is hygienic and the person able to spend time in more pleasant surroundings. All the clinical waste bins are to be assessed to ensure they are in working order to prevent the risk of spreading infection within the home. The manager should carry out an audit of all recruitment folders to ensure that the necessary documentation is in place. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 8 The home is to establish and maintain a system for evaluating the quality of the services provided at the care home and supply a copy to CSCI. The home should contact the fire officer immediately to seek advice about the fire exit door being wired together which does not allow this door to be used as an escape route. Advice must be sought from them as to the suitability of storing combustibles in a closed cupboard with a radiator that is on at all times and is not covered. As the refurbishment of the home has not taken place uncovered radiators must now be protected to ensure the comfort and safety of people who use the service. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3, 6. Quality in this outcome area is adequate. This judgement has been made using a range of evidence including a visit to this service. People who use the service do not have information about the home in order that they can make an informed choice about moving to the home. The home’s admission and assessment procedures must be improved to ensure that individual’s needs are appropriately identified and met. Intermediate care is not offered by the care home. EVIDENCE: The inspectors sampled the home’s Statement of Purpose that was supplied at the time of the inspection. Following the inspection it was noted that the document did not outline the information required in respect of the Care Homes Regulations 2001 Schedule 1 (as amended July 2006). It is required that the Statement of Purpose is updated to include the information required and is written in plain English and made accessible to prospective individuals and people living in the home. The inspectors did not sample the home Service User Guide, as a separate document and following Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 11 the required updating of the Statement of Purpose, a summary of this document must be developed as the home’s Service User Guide. The inspectors sampled three individual’s files. The inspectors were shown one signed resident contract of the terms and conditions of stay in the home. The manager explained that one other person’s contract had not been agreed as they had only been resident since June 2007 and the other individual had been admitted to the home in 1993. The manager explained to the inspectors that she or the deputy manager undertake the care needs assessments for individuals prior to admission to the home in order to ensure that the home could meet the individual’s needs. Whilst sampling the file for the person newly admitted to the home it was observed that some details were available to assist staff to support the individuals needs, however the manager explained that some details had not been gained as the home had to rely on relatives to supply the information. Intermediate care is not offered by the care home. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using a range of evidence including a visit to this service. The health and personal care that people receive is based on their individual needs set out in their care plans. Monitoring of risk assessments must be improved and maintained to ensure the safety of people in the home. There was not clear demonstration that medication was administered to all individuals in a safe and appropriate way. People’s dignity and respect are not fully promoted. EVIDENCE: The inspector’s sampled three peoples care plans, which were formed to include statements of care. It was noted that the statements detailed a variety of areas of the persons life which included, health, personal care, mobility, social and domestic activities, likes and dislikes, ethnicity, some risk reduction plans, daily records including night reports, medication and visiting professional record sheets. The statements in place also included a ‘target ongoing’ statement and an evaluation sheet, which was used as a tool to review the care plans. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 13 Whilst the plans were in place it was discussed with the manager that the format of the care plans be reviewed and expanded, for example, using one care need with identified goals and assessment with evidence of reviews having taken place at least once a month in order to ensure that the current needs of the individual are met. The care plans daily records were not fully signed by staff, for example first names, and it is recommended that full staff signatures be used in order to ensure the accuracy of reporting. During the inspection in November 2006 it was recommended that more detail of the interactions between individuals living in the home and staff be recorded to demonstrate that the holistic outcomes, i.e. the personal and social needs of individuals were being met. It was noted that the home have introduced a computerised care planning system, however further improvements are required with regard to the documentation of evidence that outcomes for individuals are being achieved. Whilst sampling the care plans the inspectors observed that the plans included statements regarding identified hazards, for example individuals getting burnt in the garden, falling out of bed, eating and drinking in bed, sitting in soiled pads, smoking and being in the community. Some care plans included a separate risk assessment (risk reduction plan), which detailed the actions in place to minimise the risk to the individual, however this was not evidenced as consistent practice. There was no evidence in some care plans to demonstrate that the hazards identified had been further developed to include a full risk assessment in order to ensure the safety and well being of the individual. It has been required that a full review of the current risk assessments be undertaken to ensure that all the hazards in peoples’ daily lives are clearly documented, measures are in place to ensure their safety and well being and reviews are undertaken at appropriate times. The manager stated that the home have the support of a local general practitioner (GP). Individuals or their representatives can request a home visit by the GP at any time. The manager stated that a prescribing nurse visits the home every week and is able to make decisions to evaluate the need for a GP visit. On the day of the inspection the inspectors met with a visiting district nurse who advised that they visit the home regularly to undertake dressings and any other tests ordered by the GP. Records indicated that healthcare professionals visit the home and individuals attend appointments, which included optician and chiropodists. The home advised that an incontinence nurse visited the home and organised the issue of incontinence products. During the tour of the premises the inspectors observed one individual in bed at midday. The individual stated that they thought they wanted to be in bed Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 14 and it was observed that they had a chesty cough. The senior care assistant on duty advised the inspectors that the individual had been seen by the nurse who was going to reassess the individual’s health and would inform the GP if necessary. Whilst sampling the care plans it was observed that the individuals are weighed periodically. It was noted that one individual had not been weighed since October 2006 and no nutritional risk assessments had been developed for people in the home. The manager stated that some individuals could not weight bear in order to be weighed. There was no evidence to demonstrate that if individuals could not stand on the home’s weighing scales that any other form of monitoring peoples’ weight took place. The manager was asked about the systems in place for these individuals and stated that the home could assess weight gain and loss by the fit of people’s clothes. It has been required that the home develop a robust system for assessing individuals nutritional status and actions are in place to record individuals weight gain and loss. During the tour of the premises the inspectors observed that the medication trolley was stored in the staff room. The room was observed to be very untidy and cluttered. Cleaning equipment, for example a carpet cleaner and hoover, were placed in front of the medication trolley and in order to gain access to the trolley staff would have to move the items. A previous requirement made during the inspection of May 2005 that the staff room/medication store must be tidied and redecorated has not been maintained. A requirement has been made that the storage arrangements regarding the medication trolley are reviewed in order to ensure the safety of staff whilst handling medication. It was observed that controlled drugs, for example Temazepam, were dispensed into blister packs and stored in the medication trolley. A previous requirement made at the May 2005 inspection detailed that a controlled drug cupboard which complies with the Misuse of Drugs (Safe Custody) Regulation 1973 is provided for the secure storage of any Controlled Drugs which are prescribed for indivduals in the home. The manager stated that the home now has a controlled drugs cupboard which is sited in the bungalow. Following the inspection an inspector spoke with the deputy manager on the telephone who advised that a further drug cabinet with secure controlled drug storage facility is to be purchaesd and sited in the care home. In consultation with the CSCI Pharmacy manager it was confirmed as best practice to store Temazepam within a controlled drugs cabinet and this reccomendation has been made. Procedures for administering medication in the home confirmed that two senior staff always undertake the administration of medication. The inspector was also advised that the blister pack rack is taken to a further trolley in order that the medication can be taken to the individuals. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 15 The home have a monitored dosage system supplied by a local dispensing chemist. The medication administration sheets were sampled and whilst they were orderly it was noted that the records contained several gaps in staff signatures. A requirement has been made that accurate records must be kept of all medication administered to individuals. The medication administration sheets did not contain any information regarding individual’s known allergies, how individuals preferred to take their medication and a recent photograph of the individual. It is recommended as best practice that these measures are introduced. The inspectors observed staff knocking on bedroom doors and speaking courteously to individuals. Arrangements are in place for individuals to receive their visitors and visiting professionals in private, however the inspector observed one individual receiving care from a visiting professional in the dining room. The inspectors were advised that the individual was not being supported in their room, as it would have been too difficult to assist the person to their room. It is recommended that when individuals are receiving healthcare visitors that they are encouraged and supported to use private facilities where possible. The general appearance of individuals in the home demonstrated that care and attention had been made by the care staff to ensure that individuals were appropriately dressed and groomed. One individual noted by the inspectors looked unkempt. The manager and a staff member explained that the individual had no independent access to money apart from a small weekly personal allowance so the home purchased the person’s clothes from a local charity shop. It is recommended that the management of the home contact the individual’s care manager in order to raise this concern as the last care plan review was held in 2005. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. Individual’s rights to exercise choice in the daily lives are promoted by staff. Bonds are maintained with family and friends. Further consultation with people and their representatives regarding shared recreational activities must be reviewed. The home provides a healthy and balanced diet. EVIDENCE: The inspectors observed that people moved freely around their home and had a choice to sit in the lounge dining area or to spend time in the privacy of their own bedrooms. One member of staff was observed in the lounge to be playing ball with the majority of the people in the home. The AQAA that was completed by the manager advises that the activities programme is generally based on group activities organised by care staff and also includes details that people are supported in their cultural lifestyles and religious beliefs. Written comments received by the CSCI and people in the home included ‘things can be rocky here’. One care plan sampled documented that an individual regularly goes unsupervised to the local shops and library and is well known in their Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 17 community. The care plan states that the individual does not participate in the organised activities as they enjoy their own company. Whilst sampling records it was noted that some external entertainers visited the home to offer musical group activities. The records showed that at least sixteen individuals were included in the activity and paid a fee for participating. It was unclear whether participants had chosen to attend this activity. It has been recommended that some form of documentation to confirm individual’s or their representatives choice and wishes to participate in paid group activities is obtained in order to confirm their views and safeguard their welfare. During the tour of the premises it was noted that one person was in their bedroom reading a paper with an extra light to improve the lighting in the room and assist with his reading and had their own belongings in room. No comments have been received from people’s relatives or friends regarding the home and no visitors were observed in the home during the inspection. Some care plans indicated that individual’s relatives and friends were involved in the lives of their relatives and friends. The home employs a full time chef. The chef advised that an environmental health inspection had been conducted eight months ago and requirements had been met. In addition the home provides meals on wheels to people living in the local community. Comments received from people in the home regarding the meals were favourable and at the midday meal it was noted that all individuals ate their meals, which looked appetising and hot. The chef advised that a choice of meals was available and this was evidenced on the day of inspection to include a vegetarian dish, fish and a meat casserole. The inspector observed the lunchtime and noted that all people were offered soft drinks. Dining tables were available for people to sit at with up to three or four people. Some condiments and appropriate crockery were available. Staff were observed to be available to support people in a caring and dignified manner with their mealtimes should they need any assistance. The dining area was clean throughout. The inspectors noted that there were two phones in the dining room. The staff advised that the staff and people living in the home used the phones and if no one is in the office the calls come through to the dining room. The inspectors questioned the rights for people to have their phone calls in private and the manager advised later in the inspection that phone sockets were available in peoples’ bedrooms and arrangements could be made for private phones lines to be put in place. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is poor. This judgement has been made using a range of evidence including a visit to this service. People who use the service have access to a complaints procedure. People who use the service are not fully protected from abuse and all staff must receive safeguarding adults training to ensure that people in the home are protected. EVIDENCE: The home has a complaints procedure. The manager advised that no complaints had been received by the home; however when sampling some recent quality assurance records from visitors some dissatisfactions and concerns had been raised. The records indicated that the home’s deputy manager had addressed some of the concerns and it has been advised that these records are transferred into the complaints log in order to demonstrate that effective responses have been made following the home receiving the views and concerns. The AQAA advises that all relatives are actively encouraged to raise any concerns at any time. The manager has stated that she had received no complaints yet the AQAA supplied to the CSCI states that three complaints have been received. One complainant has contacted the commission with information concerning a complaint made to the commission since the last inspection and this had been brought to the manager’s attention for investigation. The home has logged this complaint yet it is unclear if this has been resolved. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 19 The CSCI have made a requirement that the home supply the commission with a statement containing a summary of the complaints made during the preceding twelve months and the actions that have been taken in response to any complaints received by the home. The manager advised that the home has had no safeguarding referrals. The inspectors sampled the home’s safeguarding policy, which stated that the manager would undertake an investigation if any alleged abuse was reported. The inspectors advised the manager of the local authority safeguarding protocols and sampled that the home has the local authorities multi agency procedures for safeguarding adults dated 2001. The AQAA details that the home follows these procedures, however it is required that the home obtain the most recent procedures and protocols dated 2005 in order to safeguard vulnerable people in their care. The daily records of one person newly admitted to the home indicated that they had episodes of distressed behaviour which included going into other peoples rooms, taking clothing and moving furniture. In addition the records and staff advised that the individual had pulled another individual from their bed. Whilst sampling the records in the home the inspectors noted that this information had not been reported under the local authorities multi agency safeguarding vulnerable adult procedures. It is required that the home must make arrangements to prevent individuals being harmed, suffering abuse or being placed at risk of harm and abuse. One care plan sampled an incomplete missing persons form and there was evidence that staff had reported concerns related to one individual in the home touching staff and other individuals in the home inappropriately. The manager was unable to locate staff training records related to safeguarding awareness training and advised the inspectors that she had undertaken the safeguarding training but was unable to locate her certificate. It is required that safeguarding adults training is made available in order to ensure that staff are aware of the protocols regarding reporting and detecting abuse in order to safeguard people in their care. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is poor. This judgement has been made using a range of evidence including a visit to this service. The home does not enable the people who use the service to live in a safe and well-maintained environment. The home is clean, pleasant and hygienic in most areas. EVIDENCE: The inspectors undertook a full tour of the premises and identified significant shortfalls in the home’s environment. In discussion with the registered manager the inspectors were advised that there had been ongoing consultation with Waverley Council since 2005 regarding the proposals of extending the care home. Several applications have been rejected by Waverley Council and have been subject to appeal by the home’s owners. The inspectors were informed that the current situation is that the building plans have been amended and Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 21 re-submitted to Waverley Council in 2006/2007. The registered manager advised that the home are still awaiting the approval and will seek as a matter of urgency and inform the CSCI of the start date for the commencement of building works in order to ensure that the home is fit for purpose. The significant shortfalls in respect of the home are as follows: The poor lighting in various areas throughout the home, for example in bedrooms, dining area and hallways was observed. A requirement has been made that the lighting in identified areas of the home must be improved in order that individuals have adequate lighting to ensure their safety and comfort. It was also noted that there were broken light fittings in the corridor. During the inspection in May 2005 it was required that all rooms on the first floor had locks fitted to windows to ensure the safety and well being of the individuals in the home. It was noted that in one bedroom no restraint had been fitted to a window, which had a significant drop. The manager stated that restraints were unable to be fitted to metal framed windows. A requirement has been made that a lock is fitted to the window in order to ensure the safety of the individual in the bedroom and to assess all other windows on the upper floors to ensure they have restraints also. During the tour of the premises the inspectors noted that a malodour was present in one individuals room. A requirement has been made that the home make arrangements to eradicate the malodour in order that the individual’s bedroom is hygienic and the person able to spend time in more pleasant surroundings. In one bedroom the inspectors noted a broken wooden wardrobe structure, the base of the external patio door was rotting and a wasp nest under the hanging tiles by a window all of which were identified as hazardous. The manager advised that the individual would be distressed if the wardrobe structure was removed. A requirement has been made that the rotting door is repaired or replaced, that appropriate arrangements are made for the destruction of the wasp’s nest and the broken wardrobe structure in the individual’s bedroom is removed. The manager advised that removing the broken wardrobe would cause distress to the individual and the inspectors have required that if the structure cannot be moved then it is risk assessed in order to minimise any risk to the individual. LAUNDRY, MEDICATION AND STAFF ROOM The room was observed to be very untidy and cluttered. Cleaning equipment, for example a carpet cleaner and hoover, were placed in front of the medication trolley and in order to gain access to the trolley staff would have to move the items. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 22 The laundry was small, untidy cramped and looked dirty and cluttered. The standard of infection control in the laundry area needs to be improved as the inspectors noted that there was clean laundry in the same vicinity with soiled laundry. There are no changing facilities for staff and no security offered for their handbags/personal items. LOUNGE The ceiling decoration is in a poor state due to some water damage. The staff stated this had happened some time ago when there was a problem with the bathroom above but the manager stated that this was a recent problem and they would decorate it. The housekeeper was observed to be working hard to clean all the communal areas and all bedrooms. She was working with a vacuum cleaner that had been taped together. This has been mentioned to the manager who said that she would replace this piece of equipment. INFECTION CONTROL It was noted that in the laundry area and a communal bathroom that soiled incontinence pads had been disposed of without attention to the spread of infection. The staff member advised that generally clinical waste is double bagged to ensure control of infection practice. It has been required that the management of clinical waste is reviewed and the use of clinical waste bins in communal areas and the laundry area is ceased. Two clinical waste bins were broken which included one without a lid and one with an ill-fitting lid. The home must assess all clinical waste bins to ensure they are in working order to prevent the risk of spreading infection within the home. DOWNSTAIRS TOILET It has been required that the torn window blind in a communal toilet is replaced in order to ensure dignity and privacy for people using the facility. BATHROOMS In the Apollo bathroom the flooring is in a state of poor repair and clutter including an old piece of carpet has been stored in the unlocked boiler cupboard. Cracked tiles were observed in these areas and all bathrooms need to be decorated and assessments made as to the suitability of the baths that are in place due to the growing dependency of the people who use the service. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 23 Garden Back garden is inaccessible for people to use, the concrete pathway was noted as cracked and covered with moss, the grass area was overgrown. The area had the remnants of an old bonfire and it was noted that an old boiler was in the garden, which the inspectors were advised had been there for years. An iron gate had been secured and a small iron fence with a gate was noted. The manager explained that a fence protected the perimeter of the grounds. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have their needs met by the staff available but are not always in safe hands. Recruitment procedures are in place but gaps were noted and there was little evidence to show that staff are trained and competent to do their job. EVIDENCE: The staffing in the Wychwood on the day of the inspection included 3 carers and a carer who was undertaking an induction to the home and two carers in Wychdale, which is the bungalow. Rotas were supplied to us on request, which demonstrated that the deputy works six days a week and is usually on call for the home every day also. Some of the staff work very long hours but in the recruitment folders sampled there was no evidence that they had opted out of the working time directive. Some of the staff have completed their National Vocational Qualification (NVQ) in care and the manager states in her AQAA that this training is ongoing; however the records we sampled did not have evidence of induction having taken place or NVQ training in progress. The completed AQAA document states that English lessons have been introduced at the home but again there was no evidence that this was taking place and we found that some of the staffs English was poor and this had also been stated in a completed survey which states ‘it is difficult to make them understand when English is not their Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 25 mother tongue’. A health care professional also stated that some carers English is poor therefore making communication difficult. We sampled three recruitment folders and found that for some staff a recruitment agency is used who will also do some pre employment checks. Some shortfalls were noted. One carer that was employed had worked at another home very recently but no references had been sought from that home and they were working on that Criminal Records Bureau (CRB) check with no evidence of a CRB for this home. It is a requirement that the manager does an audit of all recruitment folders to ensure that the necessary documentation is in place. The manager stated that mandatory training has taken place for all staff but these records could not be found therefore a requirement was made that the training plank for that year to include training that had taken place and training that was planned be forwarded to CSCI. The completed AQAA states that the home’s training programme included specialist modules in dementia and challenging behaviour. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use the service do not live in a home that is well managed and is not run in the best interests of them. Health and safety of these people are not promoted or protected. EVIDENCE: On arrival at the home the inspectors were met by the people in the small office outside who asked the inspectors to wait before entering the home. The inspectors entered the home after a few minutes by which time they had been met by the carer in charge. The telephone in the dining area rang and it was the provider/managers husband to speak with an inspector Mrs Garrett. Ms Magnier wrote part of the conversation from earshot, which included a request from the provider/managers husband to cease the inspection and to hold it another day as his wife, was not available and the deputy was at home as she Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 27 had covered the night duty due to sickness. Mrs Garrett advised that the key inspection would proceed as CSCI had received information from the manager about dates that were not convenient and the inspection would therefore proceed. The inspector advised that the inspection would be going ahead with the support of the senior carer who had been left in charge of the home. The inspectors were then advised by the chef that the deputy was on her way back to the home as she had been told to return to assist with the inspection. On her arrival we said that she should go home as she must be very tired but she insisted on staying. The manager arrived at the home at lunchtime. Several documents and folders were required that were stored in the administration block and after a couple of journeys the inspectors offered to continue in the other office or we could fetch some of the documents. The offer was declined. The manager stated that she is also the provider and both names appear on her certificate. Certificate of Registration incomplete, for example, the home did not have openly displayed the categories and conditions of registration in respect of the home. It was noted that in the external office that the Certificate of Registration had been photocopied.. The manager has not yet completed her registered managers award but she stated that she was about to re-start with another provider. It is recommended that she starts this course as soon as possible and provide details of the course to CSCI. There was no evidence that the manager has had any recent training although she stated that she has updated her knowledge but the certificates could not be found. The deputy manager is in day to day charge of the home and the manager stated that she has just completed a Diploma in Dementia Care and shares her learning with relatives and staff. She has also completed her registered managers award. There was no evidence of quality audits having taken place. In the completed AQAA the manager states that they install and operate an effective quality assurance and quality monitoring systems. The manager states in the section what they could do better – ‘we also recognise that there are shortcomings with our quality survey and need to amend this to ensure we have a good tool for people to feedback on the quality of service we provide’. There will be a requirement that the home establish and maintains a system for evaluating the quality of the services provided at the care home and supply a copy to CSCI. The inspectors observed that the fire escapes leading from the lobby and lounge area raised concern. The fire door in the hallway/lobby had been secured with plastic cable ties, which would not have been able to be broken quickly in an emergency. In addition a table and curtain obstructed the fire Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 28 door in the lounge and the alarm to raise awareness that an individual was leaving the lounge was switched off and staff appeared unaware of its use. An immediate requirement has been made that the Fire Officer is contacted before 15.08.07 as a matter of urgency to be alerted to the shortfalls. The inspector telephoned the care home on the afternoon of the 15.08.07 and was advised by the manager that she had had difficulty contacting the Surrey Fire Service. A requirement had been made at the last inspection in November 2006 that a risk assessment be undertaken for all radiators and hot water pipes in areas which are accessed by residents and appropriate action taken to ensure residents welfare and safety pending the refurbishments plan. It was noted that the home had undertaken a risk assessment, which stated this would be reviewed in the summer of 2007. As previously documented the home have not commenced the refurbishment plan and it was noted that several radiators remained uncovered, which included the communal lounge area and individual’s bedrooms. The inspectors also observed a radiator in a cupboard in the laundry room, which was being used as an airing cupboard. It was noted that articles of bedding and people’s clothes were stacked against the radiator in the enclosed space. This practice was viewed as potentially hazardous and a requirement has been made that this practice of storing combustible items is risk assessed in order to prevent the outbreak of fire and ensure the safety of all people in the home. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 X X X X X X 1 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 1 Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(1) (a-c) (2)(3)(ab) 5(1)(a-f) (2)(2a) (a-b) (3)(4) 5(a-b) 6 Schedule 1 14(1)(ad) (2) (a-b) 15 (1)(2)(ad) Requirement The home’s Statement of Purpose and Service User Guide must be updated. Copies must be made available to prospective individuals and people living in the home. Copies of both amended documents must be sent to CSCI local office. Timescale for action 13/09/07 2. OP7 The care plans must be reviewed and expanded to clearly demonstrate how individual’s needs in respect of health and welfare are to be met and outcomes for individuals are being achieved. 13/09/07 3. OP8 13(4) (b & A full review of the current risk c) assessments be undertaken to ensure that all the hazards in peoples daily lives are clearly documented, measures are in place to ensure their safety and well being and reviews are undertaken at appropriate times. DS0000013845.V344548.R01.S.doc 13/09/07 Wychwood Version 5.2 Page 31 4. OP8 12(a) 5. OP9 13(2) 6. 7. OP9 OP10 13(2) 12(4)(a) 8. OP16 22(8) 9. OP18 13(6) 10. OP18 13(6) 11. OP18 13(6) 12. OP19 13(4)(a) The home must develop a robust system for assessing individual’s nutritional status and actions are in place to record individuals weight gain and loss. The storage arrangements regarding the medication trolley are to be reviewed in order to ensure the safety of staff whilst handling medication. Accurate records must be kept of all medication administered to individuals. The home to contact a care manager for a specific individual to review their care and the person’s entitlements to adequate clothing in order to promote their dignity and respect. The home to supply the Commission with a statement containing a summary of the complaints made during the preceding twelve months and the actions that have been taken in response to any complaints received by the home. The home to obtain the most recent local authority procedures and protocols dated 2005 in order to safeguard vulnerable people in their care. To make arrangements to prevent individuals being harmed, suffering abuse or being placed at risk of harm and abuse and any alleged abuse must be reported to the relevant authorities. Safeguarding vulnerable adults training must be made available to all staff in order to ensure that they are aware of the protocols regarding reporting and detecting abuse in order to safeguard people in their care. The rotting external patio door in DS0000013845.V344548.R01.S.doc 13/09/07 13/09/07 13/09/07 13/09/07 13/09/07 13/09/07 13/09/07 13/09/07 13/09/07 Page 32 Wychwood Version 5.2 13. 14. OP19 OP21 15. OP21 16. OP23 17. OP24 18. OP25 19. OP26 20. OP26 21. OP29 an individual’s bedroom is to be repaired or replaced. 13(4)(a-c) That appropriate arrangements are made for the destruction of the wasp’s nest. 12(4)(a) The torn window blind in a communal toilet is replaced in order to ensure dignity and privacy for people using the facility. 23(2)(j) Bathrooms need to be decorated and assessments made as to the suitability of the baths that are in place due to the growing dependency of the people who use the service. 13(4)(a-c) A restraint is to be fitted to the window upstairs in one individual’s bedroom in order to ensure their safety and an assessment to take place of the other windows on the upper floors to ensure they also have restraints. 13(4)(a-c) The broken wardrobe structure in an individual’s bedroom is removed and if the structure cannot be moved then it is to be risk assessed in order to minimise any risk to the individual. 23(2)(p) The lighting in identified areas of the home must be improved in order that individuals have adequate lighting to ensure their safety and comfort. 16(2)(k) Arrangements must be made to eradicate the malodour in order that the individual’s bedroom is hygienic and the person able to spend time in more pleasant surroundings. 13 (3) All the clinical waste bins are to be assessed to ensure they are in working order to prevent the risk of spreading infection within the home. 19 & The manager should carry out an DS0000013845.V344548.R01.S.doc 13/09/07 13/09/07 13/11/07 13/09/07 13/09/07 13/09/07 13/09/07 13/09/07 13/10/07 Page 33 Wychwood Version 5.2 22. OP33 23. OP38 24. OP38 25. OP38 audit of all recruitment folders to ensure that the necessary documentation is in place. 24(1)(2) The home is to establish and (amaintain a system for evaluating c)(3)(4) the quality of the services (5) provided at the care home and supply a copy to CSCI. 13(4)(a-c) The home should contact the fire officer immediately to seek advice about the fire exit door being wired together which does not allow this door to be used as an escape route. 13(4)(a-c) As the refurbishment of the home has not taken place uncovered radiators must now be protected to ensure the comfort and safety of people who use the service. 13(4)(a-c) Advice must be sought from the fire officer as to the suitability of storing combustibles in a closed cupboard with a radiator that is on at all times and is not covered. schedule 2 13/11/07 17/08/07 13/10/07 13/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP9 Good Practice Recommendations It is recommended as best practice to store Temazepam within a controlled drugs cabinet. The medication administration sheets did not contain any information regarding individual’s known allergies, how individuals preferred to take their medication and a recent photograph of the individual. It is recommended as best practice that these measures are introduced. It is recommended that when individuals are receiving healthcare visitors that they are encouraged and supported to use private facilities where possible. DS0000013845.V344548.R01.S.doc Version 5.2 Page 34 3. OP10 Wychwood 4. OP12 5. OP31 It has been recommended that some form of documentation to confirm individual’s or their representatives choice and wishes to participate in paid group activities is obtained in order to confirm their views and safeguard their welfare. It has been recommended that the manager starts her registered managers award course as soon as possible and provide details of the course to CSCI with the start date. Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Oxford Office Burgner House, 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wychwood DS0000013845.V344548.R01.S.doc Version 5.2 Page 36 - 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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