Inspection on 03/01/08 for Wychwood

This inspection was carried out on 3rd January 2008.

CSCI found this care home to be providing an Adequate 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 14/05/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Wychwood Headley Road Hindhead Surrey GU26 6TN Lead Inspector Pat Collins & Vera Bulbeck Unannounced Inspection 09:15 3 & 10 January 2008 rd th 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.V356830.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.V356830.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.V356830.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th August 2007 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.V356830.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 1 star. This means the people who use this service experience adequate quality outcomes. The unannounced inspection visits formed part of the key inspection process using the ‘Inspecting for Better Lives’ (IBL) methodology. This took place over two full days and was undertaken by two regulation inspectors. The report will say what ‘we’ found as it is written on behalf of the Commission for Social Care Inspection (CSCI). The registered manager, duty manager and assistant manager were present both days. Judgements regarding how well the home meets the national minimum standards for older people are based on the cumulative assessment, knowledge and experience of the home since its last key inspection. The required Annual Quality Assurance Assessment (AQAA) completed in July 2007 by the provider/manager, hereafter referred to in the report as ‘the manager’ also improvement plan produced by the manager and sent to the CSCI, were used to inform the inspection process. Both buildings were inspected, records, policies and procedures were sampled and practice was observed across both days. Discussions took place with all members of the home’s management team, individually and collectively; also with the chef, a domestic assistant, two senior care assistants and most of the care assistants on duty. Conversations also took place with a practice nurse and chiropodist, the maintenance person and administrator also five visitors during the inspection. Some people using services were consulted to ascertain their views about the home. These included individuals with limited communication abilities. Observations of their body language, appearance, care records and feedback from staff enabled assessment of their well-being. Survey questionnaires received from three health professionals, two people using services, two staff and two relatives also informed the inspection process. We wish to thank all who contributed information to the inspection process. Also all people using the home’s services, the home’s management and staff for their time, hospitality and assistance throughout the inspection visits. What the service does well: The personal appearance of people using services was overall good. Care practice demonstrated respect for the dignity of people who were able to exercise personal autonomy in their personal appearance and dress, within individual levels of capacity. A person using services commented, “ I am happy with the home, staff are lovely and caring, they look after me well. If I call staff at night they come quickly and are kind and helpful, the food is good” Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 6 Feedback was received from a relative who was positive about communication from management, keeping her informed of her mother’s wellbeing. This person commented, “ From the moment mum entered the home I felt she was treated as an individual. I feel I can trust them to care for her and in my opinion the standard of care is high. The assistant manager is ‘on my wavelength’ regarding mum’s needs. The assistant manager often phones me and puts mum on the phone when she is able to speak to me. If I wish to ring mum, it is possible”. Survey comments from professionals were “ Staff are pleasant, courteous and helpful” and “ Overall the care is good”. People using services were observed to have choice and control over where they spend their time in the home within individual levels of capacity. One person independently went out for long walks on both days of the inspection. Meals were well presented and substantial and their appearance was appetising. Staff were caring in their approach and examples of good care practice were noted. The environment was clean and overall odour was satisfactorily controlled. What has improved since the last inspection? What they could do better: Further requirements were made for improvement at the time of this inspection. Though positive to note plans for major financial investment in the home to upgrade the facilities, in the interim risk assessments and risk reduction measures should be further reviewed specific to radiator surface temperatures and the security of the front door to the building known as Wychwood. Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 7 Whilst recognising there is work in progress to improve the range of risk assessment tools and standardise care-planning formats, in the interim until information is transferred from old to new formats, it is essential to ensure the information in old formats remains accessible to staff for their reference. This will ensure current needs and staff knows risks. The need to address shortfalls in risk assessments and care plans to ensure these reflected the needs of people using services was also highlighted. This will ensure their health and wellbeing. Whilst the standard of catering is good, people accommodated in Wychdale must be offered the choice of meals featured on the menu. Shortfalls in the staff induction, training and development programme were identified though it is acknowledged that a programme of staff training was being implemented. It was found that language barriers between individual staff members and people using services were problematic in terms of communication. A number of shortfalls in fire safety had been recently identified through the home’s fire risk assessment. The report of this risk assessment had just been received at the time of the inspection and the home’s management not yet had opportunity to draw up an action plan to address the same. The home manager was confident however that most of these shortfalls would be addressed in the first phase of the imminent upgrading programme. The need to review the home’s fire evacuation procedure was also identified. 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.V356830.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.V356830.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards: 1,3, 6 People who use the service and their representatives mostly have the information they need to make an informed choice about the home’s suitability to meet individual needs. Pre-admission assessments were not found on four of the six files sampled to evidence these had been carried out as stated by management and in accordance with the home’s admission policy and procedure. Intermediate care is not provided. EVIDENCE: The statement of purpose, which is a document stating who the home is for, also the service user guide, which states how the home works, is in a binder in the front office. This office is in a separate building to the care home premises. The binder also contains other information that includes the complaint procedure, brochure and a sample contract. The manager was advised to include a copy of the latest inspection report in this binder as this forms part of the service users guide. It was noted that work is in progress to collate the Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 10 information in the statement of purpose and service users guide into one document. The manager stated that when prospective people using services, or more usually, their representatives, visit to view the home, they are offered opportunity to look at the information stored in this folder when they meet with the manager. The assistant manager then accompanies them on a tour of the home. We suggest 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. It was stated this had been the practice in the past but people using services had removed and destroyed these documents. It was noted that it was the intention to display this information in the home on completion of the building programme. We suggested that copies of these documents be available in the office in Wychwood and of the latest inspection report in the event prospective people using services might wish to look at them after touring the home. Also discussed was the need to offer people using services that would like one, a personal copy of the service users guide and opportunity to read the latest inspection report. It is good to note feedback in surveys from relatives and people using services indicating most felt they had received sufficient information to make an informed decision about the home’s suitability. In response to initial inquiries about placements, the manager said a brochure and copy of the complaint procedure is sent out by post. The brochure summarises the home’s services and facilities and includes other relevant information, including a charter of rights and service aims and objectives. Reference to provision of day-care made in the brochure was discussed and clarified this service is no longer offered. The manager and assistant manager both stated that they individually or jointly undertake pre-admission assessments prior to admission. It was stated that background information including social and medical histories are sought, also copies of any assessments and reports undertaken by other professionals. Pre –admission assessment reports were sampled for two people accommodated in Wychdale. These had been produced by management following the home’s own assessment. On three of the four files sampled in Wychwood however, pre-admission assessment information was not available. We received assurances from management that the needs of these people had been assessed before admission, to be confident they could be met. It was not known where these assessment records were as we had been informed that other than one person who had lived in the home for many years, that the files examined were a comprehensive collection of records held by the home on each individual. Areas of discussion with management included the need to incorporate use of validated assessment tools, for example, relating to moving and handling, falls, tissue viability/ pressure sore prevention and assessment of nutritional status, as part of pre-admission and on going assessment practice. Wychwood DS0000013845.V356830.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards: 7,8,9,10 There is good evidence of an individualised approach to care and the principles of respect, dignity and privacy are put into practice. Medication practice is mostly satisfactory; arrangements are being made to improve the storage of controlled drugs and monitor record keeping in the controlled drugs register. Risk assessments need to be further developed and care plans updated to ensure these reflect the current needs of people using services. EVIDENCE: Twenty- three people were using the home’s services at the time of the inspection. Observations confirmed good care and attention given to their personal appearance; also respect for their age, dignity and personal preferences in choice of clothes and hairstyles. Arrangements for personal care can be flexible and responsive to individual needs and wishes. It was positive to observe staff promoting independence within individual levels of capacity, though important that record keeping evidences assessment of capacity and risk. For examples, in respect of people who go out for walks in the community or attend day centres without staff support and when independently using stairs. It is acknowledged that the assistant manager stated these risks had Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 12 been assessed but this was not evident by record keeping practices. At the last key inspection on 13th August 2007, a requirement was made that stated “ A full review of the current risk assessments must be undertaken by 13th September 2007, to ensure that all the hazards in people’s daily lives are clearly documented, measures are to be in place to ensure their safety and wellbeing and reviews undertaken at appropriate times”. The evidence showed that at this key inspection this requirement had still not been met. The serving of a statutory regulation notice is being considered in respect of this breach of regulations. All people using services are registered with a general practitioner (GP). The home’s brochure states that people admitted to the home will transfer to the home’s GP unless registered with another practice in Grayshott. The GP visits as required. A practice nurse with an extended role in which she can prescribe medication, visits weekly and liaises with the GP. At the time of this inspection district nurses were also providing twice - weekly input to the care of a person using services. Aids and equipment were available in the home to meet needs and support people using services in activities of daily living. Some of this equipment including pressure- relieving mattresses had been purchased and some was stated to be on loan. Feedback from healthcare professionals included positive comments about standards of care and about staff. Two professionals however were of the view that staff required more training, one stating that staff did not have the skills to manage challenging behaviours associated with dementia. It is acknowledged that the home’s management has carried out a training skills analysis for the team. A programme of staff training is planned which includes dementia care. Some care staff do not have English as their first language. Language barriers limited the capacity of some to converse with people using services. Communication with some staff from overseas during the inspection visits established their awareness of the day-to-day needs of the people they were caring for. A senior care assistant stated that in the first three months of employment of all new care staff, she goes through care plans with them, ensuring their understanding of individual needs. Staff were directly supervised in Wychwood by senior care staff and the assistant manager. Supervision of practice was minimal in Wychdale however throughout both days of the inspection visits. Comments from a staff member supported this direct observation. When querying with the manager why a person using services had a bed rail fitted on her bed in this unit, which she did not need, the manager did not know and stated her visits to Wychdale were infrequent. Feedback from a professional during the inspection, who regularly visits the home, was complimentary of all staff, including those for whom English is not their first language. It was stated they are good at picking up on none verbal forms of communication. Without exception those people using services, relatives and visitors consulted had high regard for all staff, describing them as Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 13 very caring. Comment was received from a relative however, who though satisfied that staff had the necessary skills, felt it was important they be fluent in English. This person expressed opinion that this was essential to meeting her mother’s needs. A person using services stated in a survey that the comprehension of the English language of some staff was a problem at times and stated they could not always respond to her needs for this reason, as they did not know what she was asking for. The home’s management is aware of these issues and in the past made arrangements for staff to have support from a college, whilst on duty, to improve their language skills. This provision is no longer available from the college. A care assistant who had recently taken up post stated she was studying English in her spare time, which she funds herself. Care records were stored on open shelving in unlocked offices in Wychwood and Wychdale. It is suggested this be reviewed to ensure confidentiality of these records. Care plans and care records of six people using services were examined, four in Wychwood and two in Wychdale. Judgements about pre-admission assessments care planning and risk assessments have been based on these observations. Significant shortfalls were identified in this area. Care plans, where these existed, required updating to reflect current needs and risks and care notes were not sufficiently detailed. Examples of shortfalls included an omission to undertake a nutritional assessment and address the needs of an individual admitted with a history of an eating disorder and ensure regular monitoring of the weight of this individual. In recent months the needs of this person had substantially changed and the home has not got weighing scales to enable the weights of people unable to stand to be monitored. This person was now cared for in bed on a 24-hour basis however the care plan had not been fully updated to reflect the current high level of needs, risks and dependency of this individual. Undated and unsigned handwritten comments had been recorded on the care plan in an effort to update it in parts. Moving and handling risk assessments were not in place and no information to demonstrate pressure sore risk prevention planning and practice by staff. Though it was evident from records this person received input from the district nurses who were responsible for pressure sore risk assessment and monitoring, it is essential for care plans to also address staff’s responsibilities for pressure sore prevention. Advice was give on the importance of maintaining records of positioning and turning, to ensure continuity of care and the health and comfort of this person. This person was unable to eat or drink on her own and observations confirmed only small amounts of food and fluid taken during the inspection visits. This information was not recorded and a care plan not in place to ensure adequate nutrition and hydration. Care notes did not evidence this individual being offered any dietary supplements. It was not evident from the records available to us that a nursing needs assessment had been requested, to establish whether the needs of this person would be more appropriately met in a nursing home environment. Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 14 At the time of the last key inspection on 13th August 2007 a requirement was made that stated, “ 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 by 13th September 2007”. The evidence showed at the time of this key inspection that this requirement had still not been met. The serving of a statutory notice in respect of this breach of regulations is being considered. Whilst acknowledging information that work was in progress to further develop and improve care plans and risk assessments, it was concerning to find that on the second day of this inspection, files had been cleared of care plans and risk assessments. These had been replaced with blank care plan formats. At feedback the importance of maintaining all care records, together whilst transferring the information to new formats was emphasised, to ensure continuity of care and the safety of people using the home’s services. Medication storage remained unchanged. Access to the medication trolley in Wychwood had improved. Overflow medication was stored in a locked filing cabinet in Wychwood and there was a metal medication cupboard with storage for controlled drugs in Wychdale. A medication policy was available in Wychwood. Management stated that there was one and would ensure this was found. Controlled drugs prescribed for people in Wychwood were not stored in a controlled drugs cupboard in accordance with statutory requirements. A controlled drug cupboard is on order however and this shortfall will be imminently addressed. The assistant manager following the visit followed up an omission in record keeping specific to the controlled drug register in Wychdale. It was confirmed that there had been no medication error and arrangements were in place for monitoring medication record keeping practice. Medication training for staff is provided through pharmacies and includes practice assessments. The majority of staff had received this training and only trained staff are designated responsibility for administering medication. Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 12, 13, 14, 15. Policies and practices promote individual independence and choices. There is opportunity for participating in socially stimulating activities within the home and in the community. The home is flexible with visiting arrangements to support people using services in maintaining important personal and family relationships. Catering is of a good standard, providing wholesome, varied meals. EVIDENCE: People using services and staff have a good rapport, which was seen on the two days of the site visit. Staff encourage people to engage in social activities. One person was very clear he did not wish to join in all the activities on offer and his wishes were respected. He told us he liked to participate in the weekly music therapy session and to go independently to the local library where he spends a lot of time reading. It was good to observe core staff, for example the assistant manager and senior care assistants, demonstrate knowledge of the social history of people using services. This information was observed being used to stimulate conversation with a person using services, drawing on reminiscence and recall techniques. Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 16 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 clearly stated in the home’s information and contract. Satisfaction levels of people using services varied in respect of arrangements made for social stimulation. Of the two people who completed surveys, one stated there were no activities other than a session provided by an entertainer, at an additional charge that this person felt unable to pat for; the second stated activities are always available. This variance could be explained by observations that whilst staff in Wychwood are proactive in trying to meet social needs, no activities took place in Wychdale throughout the two days of the inspection visits. Staff in Wychwood spend time during the afternoons with people using services, playing cards, flower arranging, playing games examples of which include dominos, ball games and skittles, cake decorating, art and crafts, cross words, watching video films and engaging people in conversations. On the second day of the site visit a group of people using services were very clearly enjoying a music session provided by an entertainer. They were singing and playing instruments and there was much laughter and fun. One person from Wychdale was noted to have attended this session. Social events take place at the home occasionally, the most recent being a Christmas party to which relatives had been invited, though none had been able to attend. The assistant manager confirmed that most Sundays, four to six people using services attend a religious service at the local village church. At Christmas some had enjoyed a Christmas Carol concert. Various outings had taken place to garden centres and a local supermarket for shopping or cup of tea in the coffee shop. Individuals enjoyed visits to Longford Mill, which is a working mill, to feed the ducks and geese. There is a coffee morning at the British Legion premises on Wednesdays and the mini bus provides transport. Some people using services however stated it had been some time since this had been arranged. The staff member employed in maintenance work who used to drive the home’s mini-bus was noted to have just returned from a period of leave and no longer designated as a driver. The assistant manager and chef are designated drivers for the home’s two vehicles, which are both wheelchair accessible. 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. A choice of meal, including a vegetarian option, is on the menu. Two people using services in Wychwood stated they could have a different meal if requested. One stated she sometimes requested Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 17 and enjoyed an omelette. She said of the chef, “he is a good cook and all the meals are nice”. The chef stated that he often cooked alternative meals for anyone who does not want what is on the menu, for example two people using services say they are vegetarian but both eat chicken and fish. If there is red meat being served they have a different meal. We were informed however by three people in Wychdale that they are not offered a choice of meals. This feedback was given to management who agreed to review systems to ensure they are offered the choice of meals on the menu. Record keeping relating to catering was mostly satisfactory though the need to maintain records of any changes to the menu was identified. The chef stated he informs the office of the food required on a weekly basis. Fresh meat is delivered weekly and he likes to go to the supermarket and choose his own fresh vegetables. The chef was advised to restrict access to the kitchen areas used for food preparation to people wearing protective clothing and headwear, for hygiene reasons. We also advised the chef to take precautions regarding the hygiene of the canopy above the oven, which needed cleaning, to ensure the health and safety of people using services and staff. The manager was present when the kitchen was inspected and confirmed a new kitchen was planned as part of the building programme. A visit from the Environmental Health Officer in October 2007 did not raise any concerns about food safety. Practice observations during lunchtime were carried out in both dining rooms on both days. The food prepared was in accordance with the day’s menus. Portion sizes were substantial and meals enjoyed by most people using services. Pureed meals were well presented with good attention to colours and food textures. It was good to note home baked cakes and puddings which were appreciated by the people using services spoken with. Dining tables in Wychwood were set with centre- pieces of flowers and a person using services took pride in telling us she had arranged the flowers with assistance from a staff member. Practice was good at meal times, staff sat assisting people with their meals if necessary and meals were unhurried. Health and safety concerns were identified whilst observing arrangements for care assistants to carry plated meals from the kitchen in Wychwood to Wychdale on trays. On day two of the inspection the weather was cold, wet and windy. A care assistant carrying a tray with meals had difficulty in maintaining her balance whilst walking over the wet grass and slippery paving stones. A risk assessment must be undertaken regarding this practice and take into account the limited external lighting when food is transported between these buildings at suppertime, in the dark. The manager confirmed a recent discussion with the project manager for the building programme about the possibility of building a covered walkway between the two buildings. Wychwood DS0000013845.V356830.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards: 16, 18 People who use the home’s services and their representatives are able to express their concerns and have access to an effective complaint procedure. Staff recruitment practices protect people using services from abuse. Policies and procedures for safeguarding adults are in place. The management team demonstrate understanding of the local multi-agency safeguarding adults’ protocol. Staff training in abuse awareness is at an early stage and individual staff have limited understanding in this area. EVIDENCE: The home’s complaint procedure is included in the service uses guide file. We were informed by the manager that a copy of the procedure is sent with the brochure at the point of receiving initial inquiries about placements. Currently the complaints procedure is not displayed in the home. The manager said it had been in the past but removed by some people using services. 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 individual’s who wish to have one, to receive a personal copy of the complaint procedure and service users guide. The complaint procedure was reviewed last year. The contact details for the CSCI, which have recently changed again, need to be updated in the procedure. Also the home’s responsibility for investigating complaints made clear and suggested the statutory time scale for responding to complaints is included in the procedure. Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 19 A new summary record had been produced for complaints. On day one of the inspection visits the information contained in this record needed to be expanded and this was addressed by day two. Also for the one complaint received since the last inspection to be included in the summary. There was a clear record of the substance of this complaint, of the action taken and of the outcome. The letter to the complainant evidenced this matter had been dealt with appropriately and resolved. Two complaints were made to the CSCI in November 2007 about the home. Both were referred for review under the local multi-agency safeguarding adults procedure. The element relating to a flood that affected the passenger lift was referred back to the CSCI for follow up during this inspection. The manager had not had any feedback on the outcome of the other issues included in the referral. During the inspection visit the other complaint was followed up. Whilst there had been a delay in notifying us in this matter, based on all available information, it was found that this allegation was unsubstantiated. Discussions with the manager included the need to produce an emergency and crisis procedure and this was stated to be in progress. It was reported that contact had been made with other care homes locally regarding a collaborative approach to evacuation procedures. Discussions with management confirmed clarity of procedures for referring allegations or suspicions of abuse to Surrey’s safeguarding adults team. The home’s safeguarding procedure had been amended and is now in accordance with multi – agency procedures. We were informed that a DVD had been purchased on abuse, which arrived in the home on Monday 7th January 2008. Four care staff had seen the video at the time of the second visit. It was noted that the DVD is only part one of safeguarding adults training for staff which has two parts. The manager was reminded that a requirement was made at the time of the key inspection on 13th August 2007 for all staff to receive this training. As a priority all staff must undertake safeguarding adults training. For new staff, this must in future be part of their induction programme. Wychwood DS0000013845.V356830.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): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Standards: 19, 21, 23, 24, 25, 26. The home is clean and hygienic. Shortfalls in standards specific to the physical environment are imminently due to be improved through a major upgrading and refurbishment programme. Action had been taken to reduce hazards though further attention necessary in this area to ensure the safety of people using services. EVIDENCE: Both buildings were observed to be clean and tidy and odour adequately managed. The environment in Wychwood required a lot of attention to provide a comfortable and safe place for people using services. Where practicable the provider had met a number of requirements made at the time of the last inspection, 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. Fences had Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 21 cordoned off areas in the garden and trees had been cleared in preparation for building a new extension. A project manager with relevant experience will oversee the building programme. Relatives were stated to be aware of the plans and the manager said the plans are to be displayed in Wychwood for the information of people using services and visitors. The phased programme is intended to minimise disruption to people using services. The majority of bedroom accommodation will be affected by the building programme, which it is estimated will take between nine to twelve months. Those bedrooms not affected will also be refurbished. Wychdale bungalow is purpose built, has wide corridors suitable for wheelchair users and a wheelchair accessible toilet. There are six spacious single bedrooms, two toilets, a laundry room and bathroom with parker bath and Jacuzzi feature. The combined lounge/dining room is comfortable and domestic in character. Ramped access is provided to the garden terrace. Access is secure from the front door however noted that the back door not secure. Staff confirmed that there were no people accommodated in Wychdale at risk of going missing. At all times throughout the inspection visits staff in Wychdale maintained good observation of people using services. The front door was noted to require attention, as this did not always close properly. Whilst overall the standard of decor in Wychdale was good, attention is necessary to decoration in one bedroom also to water stains on the ceiling in the utility room. A rusty commode must be replaced in one bedroom. The manager agreed to remove bedrails integral to a bed after it was established the person occupying this bed did not need the same and caused this person discomfort at night. In Wychwood, action had been taken since the last inspection to improve fire safety after consulting a fire officer. Fire routes had been cleared and fire exits, which had been a concern, were now fitted with break-glass locks. The only area that was not secure in this building was the front door that did not always lock when closed, which is a potential risk for vulnerable adults who could leave the building unobserved. There was evidence of this having occurred on one occasion since the last inspection. It was established the door had been left unlocked by a visitor. The need to ensure an effective solution is found to reduce this risk was discussed with the management team. Mostly both buildings were warm with the exception of the lounge and dining room in Wychwood and a ground floor bathroom. This bathroom was used most of the morning during the first visit to the home, by the chiropodist, who explained bedrooms were not used as some people using services had difficulty in walking that far. The radiator in this bathroom had been turned off and found not to be working during the inspection when turned back on. This bathroom was previously well used as it contains a bath most suited to the needs of people accommodated in this building. The manager stated that following the last inspection a risk assessment had been carried out of all unguarded radiators throughout the home and measures implemented for Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 22 minimising risk, in areas of high risk. In terms of this bathroom this was a high area of risk owing to its proximity to the communal areas, which meant the toilet was in frequent use. People using services had a tendency to use the radiator which was low and directly beside the toilet, as a grab rail to steady themselves when getting on and off the toilet. As it was not possible to fit a radiator cover the decision was made to turn the radiator off. People using services can access another bath using a bath hoist, though this facility less than ideal. If a safe solution cannot be found to reinstating use of this bathroom, action must be taken to enable the chiropodist to treat people in the comfort and privacy of their bedrooms. It was noted that temporary radiator covers had been fitted in the lounge and dining room in Wychwood that had an adverse impact on heating in these areas. Staff were observed to offer rugs to people sat in chairs, some of who complained of feeling cold. Throughout the home there were numerous unguarded radiators, a number of which were found to be excessively hot. These were not positioned near beds or chairs however, and risk assessments had not identified these to pose the highest risk to people using services. The manager stated the cleaner was supposed to turn down the thermostats on radiators throughout the buildings as she cleaned. It was evident however on both visits that the cleaner had not been instructed to do so. The need to review the risk assessment and ensure the risk management solution is effective was discussed with management. The requirement made at the time of the last inspection to fit radiator covers to those without the same had not been met on the basis that work is imminent to upgrade the building. Under floor heating will then be fitted throughout. The radiators in Wychdale are of a low temperature surface type. A risk assessment of windows had also been reviewed and window restrictors fitted where necessary. The lounge in Wychwood is ‘homely’ and comfortably furnished. During the inspection a television was delivered replacing the existing one, which had a poor quality picture at the time of the first visit. The manager confirmed the intention for all bedrooms, after the refurbishment, to have the option of a free view TV or Internet access. Areas of discussion with the assistant manager and/or the manager included the need to provide keys to bedroom furniture for the three people in Wychdale who expressed preference to have keys. The manager stated a lockable item of furniture would be provided in all bedrooms in Wychwood following the refurbishment. The need to find a solution to the behaviour of a person using services to safeguard her privacy when in her bedroom was discussed with management. Noting this person pulls down curtains and blinds from her window, which is overlooked by neighbouring bungalows, consideration could be given to purchasing an external blind that can be operated from inside the room. Observation was made in one bedroom of worn thin bed linen, which was drawn to the attention of the assistant manager. Areas of discussion at the time included the need to ensure bed linen is in Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 23 good condition and for consideration to be given to purchasing washable mattress covers on noting the hard, cold surface of beds with the existing mattress covers. Comment was made on the poor first impressions of the home from the car parking bays overlooking the laundry room. This room does not have a blind and heaps of washing are visible. The manager stated this would be resolved when the laundry room is relocated during the building programme. Wychwood DS0000013845.V356830.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards: 27, 28, 29, 30 The home’s management has addressed shortfalls in recruitment procedures and these are now robust. The home is staffed efficiently, ensuring the health and welfare of people using services. Though evidenced that a comprehensive training and development plan is being put in place for the staff team, at the time of this inspection, much of the training of existing staff was out of date. Improvement is also necessary to the staff induction programme. EVIDENCE: Throughout both days of the inspection and irrespective of training shortfalls, examples of good care practice were observed. A number of staff from overseas confirmed they were qualified nurses though unable to practice as nurses in the U.K. People using services are benefiting from their prior knowledge, skills and experience. Staffing arrangements are detailed in rotas and discussions with staff evidenced the accuracy of these records. A domestic assistant is on duty Monday to Saturday working, from 8am until 4 pm. On Sundays care staff cover the basic cleaning. The chef works six days a week and a relief cook covers his day off. Staff do not usually work excessive hours except in an emergency, when they may do extra shifts if requested. Staff were of smart appearance in neat, clean uniforms. Care staffing levels are two throughout the waking day in Wychdale with the exception of a short period before supper when one is deployed in Wychwood. Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 25 In Wychwood there is one senior care assistant and two care assistants on duty during the day. Night staffing levels are two waking care staff in Wychwood and one in Wychdale. Observations indicated staffing levels are adequate. The home achieved Investors in People accreditation, which was awarded in 2005. A number of staff working in the home had received relevant training over a period of time, however the training is now out of date and most required refresher training. Fire training was taking place on the day of the site visit. A staff member informed us that there was no incentive to attend training courses in their own time, as they are not paid. The assistant manager stated that she had downloaded Skills for Care training from the computer, however this had not been used to date. Induction training needs to be formalised and it was not clear from the records examined which training staff had received. Some staff stated they had not received a formal induction but had been told about some procedures including what to do if there was a fire. The assistant manager was advised to ensure all staff are fully trained and training records maintained up to date. The manager emphasised her commitment to meeting staff’s training needs and was planning shared training events for staff from the two homes owned by the providers. Four staff files were sampled and contained all statutory information. Staff employed in the home prior to the previous inspection, were not checked against the national list of people unsuitable to work with vulnerable adults (POVA list) prior to taking up post. The manager had not understood she must do so, but since then had reviewed and improved staff vetting procedures, addressing this shortfall. Robust recruitment and vetting procedures were evidenced. It was noted that a recently employed member of staff did not start employment until clearance had been received from the Criminal Records Bureau (CRB Disclosure). CRB Disclosures were evidenced also for the chiropodist, hairdresser, aroma - therapist and administrator. The manager was advised to ensure CRB guidance followed in respect of recording, storage and disposal of CRB Disclosures. Wychwood DS0000013845.V356830.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards: 31, 33, 35, 37,38. The senior management team have defined roles and areas of responsibility. There is a development plan based on self-evaluation systems for improvement. Staff training and development had been inconsistent and the improvement plan we received did not provide entirely reliable information. There are shortfalls in fire safety arrangements though some improvement in this area had been achieved. Systems are in place to safeguard the personal finances of people using services managed by the manager. EVIDENCE: 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.The providers have purchased another home and plan to re-register Wychwood as a Limited Company. They would like the assistant manager to apply for registration as the day-to-day manager of Wychwood. The assistant Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 27 manager informed us that she has a National Vocational Qualification (NVQ) Level 4 in managements and the Registered Manager Award (RMA) qualification. We were told that she had also recently successfully achieved a diploma in dementia care. The manager confirmed she had still not reapplied to undertake the RMA/NVQ Level 4 qualification but may do so in the future. Communication systems include daily contact between the manager and assistant manager and weekly management meetings. The management team have clearly defined areas of responsibility and roles. Policies and procedures are under review and the statement of purpose and service users guide is being combined into one document. We were informed that work was in progress to improve and develop care plans, also the staff induction and training programme, with input from a care consultant. The management team acknowledged there was still a long way to go before all staff will have had all statutory training or refresher training. It was stated that the home’s management complete the training programme over a two-year period and generally plan it between September and December every other year and that some staff missed this owing to holidays. The home’s quality assurance systems had been developed and are now inclusive of people using services and/or their representatives. These could be further improved by use of additional quality audits and noted this is planned. At the feedback session with the management team we discussion use of the Annual Quality Assurance Assessment (AQAA) for informing the inspection outcomes. The importance of ensuring the accuracy of information in this document and the improvement plan was also discussed. A copy of the registration certificate displayed in Wychwood showed the home’s registration categories. We noted that the manager has written to us to request another certificate. The manager is appointee for one person using services. Observations confirmed systems in place to ensure this individual had access to his money and to record and maintain receipts for expenditure on this person’s behalf. We were told that the home’s management is not responsible for managing the personal finances or handling the money belonging to any other people using services. 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. A bedroom door in Wychwood was wedged open throughout both inspection visits. It was suggested that the fire officer be consulted about fitting a door guard to this door. The manager stated the building programme included fitting fire Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 28 retardant doors in both buildings that can be left open and automatically close if the fire alarm is activated. Fire instructions were available in bedrooms, stating the action to take in the event of the fire alarm sounding. The fire procedure was also displayed. Noting the evacuation procedure described a lateral evacuation system and evacuation procedures at night were not specified, we advised management to consult Surrey Fire & Rescue Service to ensure the procedures are based on best practice. The delay in notification of a significant event was discussed with management. The assistant manager confirmed the intention in future to telephone notifications to the CSCI and to then follow up with a written notification. Action taken to minimise risk in the environment since the last key inspection was noted. Some risks remain, however, for example excessively hot radiator temperatures. The need to review the risk assessment in respect of this hazard and solutions to minimise this risk was identified. Also there is a need to reduce risks of people going missing via the front door in Wychwood due to the defective lock. Health and safety risks for staff must be carried out in respect of transporting trays of food across slippery paving stones and grass from the kitchen in Wychwood to Wychdale. Wychwood DS0000013845.V356830.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 3 1 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 1 x 2 x 2 2 2 3 STAFFING Standard No Score 27 3 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x 1 1 Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 30 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. The home must have suitable equipment to enable weight loss and gain to be monitored for all people using services, to ensure their health. For attention to the maintenance and décor of Wychdale as detailed in the body of this report. For attention to the maintenance and décor of Wychwood as detailed in this report. 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 last key inspection. For all staff to receive structured induction training and all statutory and service specific training appropriate to the work they are to perform For review of the storage of care DS0000013845.V356830.R01.S.doc Timescale for action 15/03/08 2. OP8 23(n) 10/03/08 3. OP19 13(4)(c) 16(2)(c) 23(2)(b) 16(2)(c) 23(2)(b) 10/04/08 4. OP19 10/01/09 5. OP30 18(1)(c) 10/04/08 6. OP37 17(1)(b) 10/03/08 Page 31 Wychwood Version 5.2 17(3) 7. OP38 10(1) 13(4) 23(4A) records to ensure confidentiality of people using services. Records of food provision must be accurately maintained and of staff induction and training. For health and safety risk 10/03/08 assessments to ensure safe practice in transporting food from the kitchen in Wychwood to Wychdale. An action plan must be developed for addressing fire safety hazards and Surrey Fire and Rescue Service contacted to ensure the adequacy of the home’s fire evacuation plan. Hazards associated with the hot surface of uncovered radiators must be closely monitored and risk reduction action must be continuous. A safe solution must be found to the potential hazard specific to the defective locking system on Wychwood’s front door. 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 OP1 Good Practice Recommendations For the latest inspection report to be maintained in the file containing the statement of purpose and service users guide. Also for the information in this file to be duplicated and held in the office in Wychwood. A copy of the combined statement of purpose and service users guide when available, and the revised complaint procedure, to be in each bedroom and displayed prominently in both Wychwood and Wychdale. For a nursing need assessment to be carried out for the person using services in Wychdale who has high dependency needs, to determine whether these needs would be more appropriately met in a nursing home DS0000013845.V356830.R01.S.doc Version 5.2 Page 32 2. OP8 Wychwood 3. OP10 environment. It is recommended that when people using services have chiropody treatment this takes place in the privacy and comfort of their bedrooms if heating is not restored in the bathroom currently used. For an external blind that can be operated from inside the home to be fitted to the bedroom window where the privacy of a person using services is compromised by behaviours. It has been recommended that some form of documentation be in place confirming individual’s or their representatives’ choices and wishes to participate in paid group activities. For people in Wychdale to be offered keys to their lockable items of furniture. Following the refurbishment for all people in Wychwood to have a lockable item of furniture and offered keys to the same to safeguard money and personal possessions. For a minimum ratio of 50 trained staff to be in post with qualifications at NVQ Level 2 or equivalent. 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. For review of the risk assessment and risk reduction plan for safeguarding people using the home’s services from accidents caused by excessively hot surface temperatures of unguarded radiators. It is recommended for all staff and visitors to be supplied with suitable protective clothing when in the food preparation area of the kitchen. Additionally for the canopy above the cooker to be cleaned. 4. OP10 5. OP12 6. OP24 7. 8. OP28 OP31 9. OP38 10. OP38 Wychwood DS0000013845.V356830.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Oxford Office 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.V356830.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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