Inspection on 14/05/08 for Wychwood

This inspection was carried out on 14th May 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wychwood 10/11/08

Wychwood 03/01/08

Wychwood 13/08/07

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Wychwood Headley Road Hindhead Surrey GU26 6TN Lead Inspector Lesley Garrett & Suzanne Magnier Unannounced Inspection 14th May 2008 07:30 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.V364848.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.V364848.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.V364848.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2008 Brief Description of the Service: Wychwood care home is registered to provide personal care and accommodation for up to 24 older people, including people with physical disabilities, mental disorders and dementia. The registered premises comprise of two separate buildings, which are known as Wychwood, which is a detached two- storey building and Wychdale, which is a detached bungalow. There are a total of 18 single and 3 shared bedrooms all with emergency call bells and washbasins. Some have en-suite toilets facilities and others have en-suite showers or bathrooms. Assisted bathrooms and toilets are also available on all floors. Wychwood has a communal lounge and separate dining room and Wychdale has a combined lounge/dining room and domestic style kitchen. Service provision includes opportunity for community activities in the home’s wheelchair accessible vehicles. One of the providers is also the named registered manager. Weekly fees on 10/01/08 ranged from £379.22 to £700.00. Additional charges apply for newspapers, hairdressing, chiropody, some community outings, entertainment, a music activity, aromatherapy and reflexology. Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. 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 the registered manager represented the service. The registered manager is also the home’s provider. For the purposes of this report the person in charge will be referred to as the manager. The reason for the inspection was that information that the commission received highlighted concerns over the management arrangements at both the registered establishments Wychwood and The Old Manor House in Bognor Regis, West Sussex. The inspectors arrived at the service at 07.30 and were in the home for eight and a quarter hours. It was a thorough look at how well the home is doing. It took into account information provided by the home and any information that CSCI has received about the service since the last inspection in January 2008. The inspectors spent time talking with some of the people living at the home in order to seek their views about the home and the care they receive. The home was not asked to supply a further AQAA (Annual Quality Assurance Assessment). The last AQAA completed was in July 2007. The inspectors looked at how well the service was meeting the key national minimum standards and complying with the regulations and has in this report made judgements about the standard of the service. Documents sampled during 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. 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. The owners of the home have sought planning permission to refurbish the home since 2006 and during the last unannounced inspection conducted in January 2008 the CSCI were informed that the building works were due to Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 6 commence in January 2008 yet during this site visit the building works had not yet commenced. Refer to the environment section of the main body of report. What the service does well: What has improved since the last inspection? What they could do better: Ten requirements were made following this key inspection and include the following: For admissions to the home to be on the basis of full assessment of needs to be sure needs can be met. Assessments must be then kept under review. The home must have suitable equipment to enable weight loss and gain to be monitored for all the residents using the service to ensure their health. The home must develop a robust system for assessing individual’s nutritional status and actions to be in place to record individuals weight gain and loss. Arrangements must be put in place to ensure the safe administration of medicines in the home. The maintenance and décor of Wychwood, as detailed in the report of August 2007, still needs to be addressed. Also assess and ensure adequacy of lighting in parts of the home and bathing facilities that was identified to be necessary at the time of the key inspection in August 2007. The rotas must demonstrate which members of staff are actually in the building and there must be suitably qualified, competent and experienced staff on at each shift. Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 7 All recruitment folders must contain the necessary information and this applies to all new and current staff. All staff are to receive structured induction training and all statutory and service specific training appropriate to the work they are to perform Health and safety risk assessments to be put in place to ensure safe practice in transporting food from the kitchen in Wychwood to Wychdale. Following the fire risk assessment in the home during November 2007 the home must supply CSCI with an action plan of how the shortfalls identified in the report will be met, as the building work has not yet commenced. 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.V364848.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 13&6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents to the home do not have access to current information about the home, which does not allow residents to have current information about the home to make an informed decision about an admission. EVIDENCE: During the key inspections in August 2007 and January 2008 it was observed that the statement of purpose and service user guide did not contain all the information required. It was noted in January 2008 that work was in progress to collate the information in the statement of purpose and service users guide into one document. This has not been completed and the last inspection report is still not included with this document. The brochure is also inaccurate as it states the manager is undertaking her registered managers award at a local college yet the manager has advised the commission during the August 2007 and following inspections that she did not complete the course and therefore has not achieved the award. Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 10 The manager stated that when prospective residents, or more usually, their representatives, visit to view the home, they are offered the opportunity to look at the information stored in a folder when they meet with the manager. The assistant manager then accompanies them on a tour of the home. It was suggested during the inspection in January 2008 that when the combined statement of purpose and service users document is finalised that a copy be displayed, together with the complaint procedure, in a public area in both Wychwood and Wychdale. This has not been completed and the manager stated that it was the intention to display this information in the home on completion of the building programme. The manager stated that she or the deputy individually or jointly undertakes pre-admission assessments prior to admission. The chef told the inspectors that the home had one new admission and had arrived at the home the previous evening. The inspectors asked to sample the pre-admission assessment of the new resident but were told that no documentation was in place. The manager stated that the staff knew the resident, as her husband was a resident at the home, and had arrived late in the evening following a staff meeting. The manager also stated that the individual had no medical concerns. During the course of the inspection the resident was observed to come to the administration block to request that she be able to make a phone call, as she had not received her medication from the pharmacist. During the inspection in January 2008 it was required that no resident should be admitted to the home without a full assessment of their needs being undertaken to ensure that the home can meet their needs and the timescale of 15/03/08 has not been met. This is a repeated requirement and therefore enforcement action is being considered. The home does not provide intermediate care. Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Risk assessments need to be further developed and care plans updated to ensure these reflect the current needs of residents. Medication practices need to be improved to ensure the safety of the residents. EVIDENCE: Five individual plans of care were sampled and these were the same plans that were sampled in January 2008. These are typed documents but are not user friendly or holistic. The plans do not give the reader insight into the person that care is being delivered to. One of the plans had a statement on the cover to say ‘whole care plan under review’. The manager stated that the information contained within the document was still relevant just that they were completing a review on that particular resident. The current care plan format did make the information they contained difficult to review. For example there was evidence that the plans had been reviewed in April and May 2008. It was unclear when the changes had taken place as Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 12 there was a tick on both review dates, yes or no to changes, and then hand written entries were seen to reflect a change. The document was not current, as changes had not been incorporated into the plan. The manager stated that for changes to be made staff needed access to the computer, which is situated in the administration block and separated from the home. The manager stated that following the refurbishment the plan is to have a computer in the office in the home in Wychwood. Five plans were sampled and no nutritional risk assessments were in place. A requirement was made in August 2007 for the home to develop a robust system for assessing individuals’ nutritional status and actions to be put in place to record individual’s weight gain and loss. A further requirement was made in January 2008 for the home to have suitable equipment to enable weight loss and gain to be monitored for all people using services, to ensure their health. The manager stated that she had spoken with her consultant who advised that it was not necessary for the home to complete nutritional risk assessments if the district nurse had done this. There was one assessment in place for one individual written by the district nurse but no other resident had a recognised tool to measure their weight gain or loss. Timescale of 13/09/07 not met therefore enforcement action is being considered. During the inspection in January 2008 it was observed that appropriate equipment to enable weight loss and gain to be monitored for all residents was not in place. This remains the same, as there were only scales available for those residents who could walk. Timescales of the 10/03/08 have not been met and therefore enforcement action is being considered. Other risk assessments were now in place for the residents as required in August 2007 for example skin integrity and falls. Several of the individual plans sampled identified the residents as high risk but there was no care plan or action plan to identify how these risks would be minimised. Records indicated that healthcare professionals visit the home and individuals attend appointments, which included an optician and chiropodists. The home advised that an incontinence nurse visited the home and organised the issue of incontinence products. Records sampled for one individual demonstrated that the district nurse makes regular visits to the home to assess one resident who has high medical needs. Staff spoken to on the day demonstrated that they had a good knowledge of this individual’s care needs. We observed part of a medication round during the morning. Two carers were dispensing the medicines together. One carer read the medication administration record whilst seated on the arm of a chair out of view of the other carer who placed the medicines in a pot. The medicines were then placed on a teaspoon and given to the resident without explanation. The observation of the medication procedure was fed back to the manager of the home at the Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 13 end of the inspection who confirmed that the way in which staff undertook their duty was not in compliance with the homes policy and procedure. A requirement concerning this practice will be made at the end the report. 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. Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Consultation with residents and their representatives should take place to ensure that the activity programme meets the needs and benefits all of the residents. 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. It was observed that two residents whilst moving from the lounge to the dining area and hall held on to furniture and the doors and through enquiry to staff the inspectors were told that neither of the residents had any walking aids. The in - house activity programme is delivered by care staff on a daily basis. Details of the arranged activities are displayed on the wall in the hallway. We were informed that there are additional charges to the cost of fees for some entertainers who visit the home for individuals that attend these activities. This is stated in the home’s information and contract. Staff spoken to on the day of Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 15 the inspection stated that the residents had participated in skittles that morning. Two residents spoken to stated that they did not join in activities, as their personal allowance would not allow it. They stated that £10 per week or a session was too expensive and therefore they did not engage in any social stimulation but instead watched the television. It is acknowledged that the home does provide ‘in house’ activities at no extra charge to the residents. During the inspection it was observed that some of the residents lacked the capacity to make informed choices regarding activities. It is recommended that clear care plans be written in consultation with the resident and their representatives to clearly state those activities that have been agreed. This was not however evidenced in the five care plans sampled. On the day of inspection there were no visitors to the home although the manager stated there are no restrictions to visiting times. Catering arrangements are well organised. The chef works in the home six days a week and a relief cook is employed on his day off. He is aware of the food preferences of people using services and of any dietary needs. The menu is displayed on the wall in the hall outside the dining room in Wychwood. The day’s menu is written on an orientation board in the dining room that also has other information about the date, day and weather. The menu is also available in the dining room in Wychdale. The residents spoken to on the day of the visit confirmed that they enjoyed the food and the inspectors commended the chef for the provision and presentation of the meal. Residents were supported by staff to eat their meal and the soft diet that was available was well presented. Problems identified during the last inspection in January 2008 with transporting meals to Wychdale have not been resolved. The weather is now better and the morning and evenings light. The manager stated that discussions were still taking place with the builder about providing a covered walkway. No risk assessments were observed. Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 16 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 available evidence including a visit to this service. Residents are not aware of the complaints procedure. The safeguarding procedures need to be strengthened to ensure the well being of all the residents. EVIDENCE: The home’s complaint procedure is included in the service users guide file. Currently the complaints procedure is not displayed in the home. The manager said it had been in the past but removed by some residents in the home. It was suggested to management that this be displayed in a fixed frame in a prominent public area in both Wychdale and Wychwood. Also for individuals who wish to have one, to receive a personal copy of the complaints procedure and service users guide. The complaints procedure was reviewed last year. The contact details for the CSCI, which have recently changed, were updated during the inspection. The complaints log was observed and the last concern documented was in December 2007. One complainant has contacted the commission with an ongoing concern with regards to the home. Information regarding the concerns received have on occasions been passed to the proprietors to investigate using the homes complaints procedures. The evidence supports the judgement made. Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 17 During the inspection in January 2008 the inspectors were informed that the home’s safeguarding procedure had been amended and is now in accordance with the local authority’s multi–agency procedures. They were also informed that a DVD had been purchased on abuse, which arrived in the home on Monday 7th January 2008. Four members of staff had seen the DVD in January. A requirement was made in August 2007 that all staff must receive this training and for it to be included in the induction for new members of staff. Records sampled on the day did not demonstrate that staff had received this training. The residents that were able to communicate on the day of the site visit said that they would probably take their concerns to the deputy manager but they were not aware of the procedure. When asked if they felt safe in the home it was stated they did not. They stated that they heard noises from residents in the main home Wychwood which upset them. The details documented in the report are the opinions, made by people living in the home and it is suggested that the management of the home undertakes a focussed quality audit related to the specific areas in order to clarify the views of people living in the home. One of the residents told the inspector about an incident that happened in the home but this was investigated under the local authority safeguarding adult procedures. Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 18 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 available evidence including a visit to this service. The home is clean and hygienic. Shortfalls in standards specific to the physical environment have not been improved as the major upgrading and refurbishment programme has not commenced which means residents do not live in a safe well maintained environment. EVIDENCE: The inspectors were told during the inspection in January 2008 that the major refurbishment was due to start imminently. Some of the requirements made in August 2007 still have not been addressed and were not followed up during the January 2008 inspection as the manager stated the works were about to start. Part of the garden remains cordoned off in preparation of the building works since January 2008 and the manager stated that the project manager had Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 19 been unavailable and the owners were not aware of this until March 2008. The manager did not contact the commission to inform them that the building work would not take place as planned. The potential hazard of a broken manhole cover was brought to the manager and administrator’s attention and the administrator acted promptly by telephoning for the hazard to be rectified and the cordon re assembled. The inspectors noted at the inspection in January 2008 that where practicable the manager had met a number of requirements made at the time of the inspection in August 2007, which had achieved some improvement. The manager outlined how those outstanding are to be addressed through the upgrading and refurbishment programme that was imminently due to commence. The ongoing maintenance and decoration upkeep has been put on hold pending the proprietors proposed property upgrade. This has had a detrimental affect on the overall physical environment. The veranda that was written about in the inspection report of August 2007 has been fixed on a temporary basis as the door has been removed and the gap boarded up. The inspection in January 2008 identified shortfalls in the homes fire risk assessment and it was stated at that time that ‘the home manager was confident that most of these shortfalls would be addressed in the first phase of the imminent upgrading programme’. This programme has not commenced. The home remains in a poor condition whilst awaiting the building works and a separate letter has been sent to the manager for CSCI to be advised of the start date for the refurbishment to commence. During the last inspection the inspectors were told that once work has commenced it is estimated to last nine to twelve months. A requirement made in January 2008 for attention to the maintenance and décor of Wychwood was given a time scale of January 2009 this will not be met due to the building work not having started. A requirement was made in August 2007 that the bathrooms needed to be decorated and assessments made as to the suitability of the type of baths that are in place due to the growing dependency of the people who use the service. The timescale of 13/11/07 has not been met and enforcement action is being considered. During previous inspections it has been suggested that following the refurbishment for all people in Wychwood to have a lockable item of furniture and offered keys to safeguard their money and personal possessions. It was also highlighted that a review of the risk assessment and risk reduction plan for safeguarding residents against accidents caused by excessively hot surface temperatures of unguarded radiators. Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 20 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. Training, induction and recruitment practices in the home need to be strengthened to protect the residents living there. EVIDENCE: Prior to this inspection concerns were raised within CSCI of the staffing arrangements at Wychwood. Staff rotas belonging the manager’s other home were seen which indicated that the manager and the deputy manager from Wychwood were also covering the other home at the same time the rotas showed they were documented as on the rota for Wychwood. On the day of the inspection the rota stated that the deputy manager was on call and staff spoken to believed this to be the case. The inspectors were told that the deputy was sick and had been for two days. The manager stated that it was the intention for the deputy manager to manage the other home but they have now recruited a manager so the deputy manager will return to Wychwood. The staff rotas were unclear as to who was in the building and at what time. For example if the rota states ‘on call’ they are not always in the building. The rotas from the other registered home were compared with the rotas for Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 21 Wychwood and the same management team were covering both homes. The deputy manager from Wychwood had also been the person in charge of the other registered home when their registered manager had left the home. This was discussed with the manager on the day of the visit who agreed that the rotas were not clear. Staff files indicated that there was still a shortfall in some of the training provided by the home. During the inspection in January 2008 a staff member stated that there was no incentive to attend training courses in their own time, as they are not paid. Training records sampled demonstrated that the members of staff had not completed manual handling training. On the day of inspection one member of staff was observed supporting a resident to sit down. The technique used is not a recognised method of assisting a resident to move. Requirements made in January 2008 remain outstanding. Induction training for two of the staff members whose files were sampled was not fully completed. The timescale of 10/03/08 remains unmet therefore enforcement action is being considered. The home’s administrator showed the inspector that two training schedules were in place yet confirmed that neither of the computerised documentation was up to date which also included information regarding a minimum ratio of 50 trained staff to be in post with qualifications at NVQ Level 2 or equivalent. The administrator spent some time during the inspection trying to update the training matrix and the commission have requested a copy be sent to the local CSCI office. Three recruitment folders were sampled and this demonstrated that there is a shortfall in the recruitment practices of the home, which does not protect the residents. Two folders did not contain full details of references. One did not have explanations of gaps in employment and one did not contain a fully completed application form. Timescale of 13/10/07 not met therefore enforcement action will be considered. Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 22 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. The management and administration of the home is not robust. The home is run in the best interests of the residents yet their views and opinions and those of other associated with the home could be strengthened. Resident’s general safety and welfare is not promoted due to the ongoing health and safety concerns in the home. EVIDENCE: The inspection in January 2008 stated that the management team comprised of both providers, one of whom is the registered manager and an assistant manager who has worked at the home since 1996. They would like the assistant manager to apply for registration as the day-to-day manager of Wychwood. The assistant manager stated at the time of the inspection in Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 23 January 2008 that she has a National Vocational Qualification (NVQ) Level 4 in management and the Registered Manager Award (RMA) qualification. The inspectors were told that she had also recently successfully achieved a diploma in dementia care. The manager confirmed she had still not re-applied to undertake the RMA/NVQ Level 4 qualification but may do so in the future. There have been no changes to this. Since the provider purchased their other home in Bognor Regis she has not provided the day-to-day management of Wychwood. The deputy manager provided management cover for the home in Bognor Regis along with the registered manager without informing CSCI of the change in management responsibilities. Since the manager purchased another home the assistant manager has spent a lot of time at that home but the rotas observed did not clearly demonstrate which home she would be in as discussed earlier in the report. From observations on the day staff have lacked clear leadership and accountability as evidenced with the poor practice of both the administration of medicines and poor manual handling techniques. The manager stated that the last surveys to seek the views of people who use the service were completed in June 2007. It was stated that they are completed jointly between the resident and their relative. No views are sought from other visiting professionals. The manager does not hold resident meetings. The manager stated that she tried it once but the residents and relatives were not interested. There is no effective communication system within the home to feed back results of the surveys completed or to announce any changes that may occur within the home. The home does not hold any allowances for the residents on the premises. The organisation does hold a deposit of £100.00 to meet any out of pocket expenses when people leave the home. The manager stated that a refund is given when the resident dies or leaves the home. During the inspection January 2008 it was observed that a fire risk assessment was carried out on 7th November 2007 and had identified a number of shortfalls. The manager had just received this report and had not yet had opportunity to prepare an action plan for improvement. The manager was confidant that that most shortfalls in this report would be addressed in the first phase of the building programme. The building programme has not yet started therefore it will be a requirement for the manager to inform the commission of how the residents will be safeguarded until then. Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X X X X X 2 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 2 X 2 X X 1 Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14(1) Requirement For admissions to the home to be on the basis of full assessment of needs to be sure needs can be met. Assessments must be then kept under review. Timescale 15/03/08 not met. Arrangements must be made for suitable equipment to be in place to enable weight loss and gain to be monitored for all people using services, to ensure their health. Timescale 10/03/08 not met. Arrangements must be made to develop a robust system for assessing individual’s nutritional status and actions to be in place to record individuals weight gain and loss. Timescale13/09/07 not met. Arrangements must be put in place to ensure the safe administration of medicines in the home. Arrangements must be made to ensure that all staff receives training in safeguarding adults and for this to be included in the induction for all new members of staff. DS0000013845.V364848.R01.S.doc Timescale for action 14/07/08 2. OP8 23(n) 14/07/08 3. OP8 12(1)(a) 14/07/08 4. OP9 13(2) 14/07/08 5. OP18 13(6) 14/07/08 Wychwood Version 5.2 Page 26 6. OP19 23(2)(n) 7. OP27 18 8. OP29 19 & Schedule 2 18(1)(c) 9. OP30 10. OP38 10(1) 13(4) 23(4A) 11. OP38 12(1)(a) Assess and ensure adequacy of bathing facilities in all bathrooms and toilets. Timescale13/11/07 There must be suitably qualified, competent and experienced staff on at each shift, which is reflected in the staff rotas. All recruitment folders must contain the necessary information and this applies to all new and current staff. Timescale13/10/07 not met. For all staff to receive structured induction training and all statutory and service specific training appropriate to the work they are to perform Timescale10/04/08 not met. For health and safety risk assessments to ensure safe practice in transporting food from the kitchen in Wychwood to Wychdale. Timescale 10/03/08 not met. Arrangements must be in place to ensure that documented evidence is available with regard to the shortfalls identified in the homes fire risk assessment to safeguard residents’ safety and wellbeing. 14/07/08 14/07/08 14/07/08 14/10/08 14/07/08 14/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations It is recommended that that clear care plans be written in consultation with the resident and their representatives to clearly state those activities that have been agreed. Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 27 Wychwood DS0000013845.V364848.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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.V364848.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!