Inspection on 09/08/07 for Wykeham House

This inspection was carried out on 9th August 2007.

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

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

Other inspections for this house

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Wykeham House Wykeham House 21 Russells Crescent Horley Surrey RH6 7DJ Lead Inspector Helen Dickens Unannounced Inspection 9th August 2007 10:00 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 DS0000069294.V345449.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. DS0000069294.V345449.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wykeham House Address Wykeham House 21 Russells Crescent Horley Surrey RH6 7DJ 01293 823835 01293 823837 naresh.mapara@barchester.com 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) Barchester Healthcare Homes Ltd Mr Najaindranath Mapara Care Home 76 Category(ies) of Dementia - over 65 years of age (42), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (42), Old age, not falling within any other category (76), Physical disability over 65 years of age (12) DS0000069294.V345449.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The minimum admission age is 60 years Of the total number of 42 service users within categories DE(E) or MD(E) these individuals may only be accommodated in Kinnersley unit (now called Memory Lane). Of the 12 service users accommodated within the category PD(E) these may only be accommodated in High Beeches unit. Up to 12 service users within categories OP or PD(E) may be admitted for short stay or respite care and accommodated in High Beeches. N/A Date of last inspection Brief Description of the Service: Wykeham House is a purpose built care home providing nursing care for older people, some of whom have dementia or mental health problems. The home is registered to accommodate 76 people on two floors accessible by two passenger lifts. Each floor is divided into two units, High Beeches, and Memory Lane, previously Kinnersley Unit. One unit is for physically frail residents, and the other for those with dementia. The accommodation comprises single occupancy bedrooms with en-suite toilet facilities. There are four lounges and two dining rooms. The home has specialist bathing facilities and a shower room. There are kitchenettes on each unit and a hairdressing room. Residents can use the company’s wheelchair accessible mini-bus for outings. The home has its own gardens and car parking facilities and is convenient for Horley town centre and public transport. The range of fees for the home is currently from: £750.00 - £775.00 per week. DS0000069294.V345449.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over 8.5 hours. The inspection was carried out by Helen Dickens, Regulation Inspector. The Registered Manager, Naresh Mapara, represented the establishment. A partial tour of the premises took place. The inspector spoke to four residents on a one-to-one basis and talked briefly with many of the remaining residents during lunch. One member of staff and two visitors were also spoken with. Six ‘comment cards’ returned to CSCI, and a number of questionnaires on file at the home, were also used in writing this report. Four resident’s care plans and a number of other documents and files, including two staff files, as well as risk assessments and maintenance records, were examined during the day. The Commission for Social Care Inspection would like to thank the residents, relatives, manager and staff for their hospitality, assistance and co-operation with this inspection. What the service does well: Wykeham House provides a very comfortable environment for residents and both the Unit for physically frail older people, and the Unit for people with dementia, are well furnished with many homely touches. The dining rooms are particularly pleasant though all residents spoken to also liked their bedrooms which were noted to be well furnished and with many personal belongings. The bedroom doors in the dementia Unit, now called Memory Lane, all had a frame for residents to put whatever they felt would personalise the entry to their room. Care plans were well done and reviewed regularly. Residents confirmed their needs were met and staff were helpful. A number of very positive comments were received to CSCI prior to the inspection including ‘The carers and nurses are first class. On the whole Wykeham House is first class.’ There is an equal opportunities policy in place and the home employs staff from a variety of cultural backgrounds. The manager has just booked equal opportunities training, starting next week, which all staff will attend over the next several months. The home is fully accessible to residents with a physical disability and for those with a cognitive impairment, there are secure areas of the home and garden which allow residents to move around freely, but are secure enough to protect them from any undue hazards. DS0000069294.V345449.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Four Requirements have been made following this inspection including ensuring all new resident’s care plans are completed in a timely fashion, in particular their moving and handling and nutritional risk assessments. The were also some decorative and health and safety matters, namely ensuring potentially hazardous liquids are secure at all times, and reviewing infection control measures including a few areas which were not odour-free. DS0000069294.V345449.R01.S.doc Version 5.2 Page 7 Some negative comments were received from visitor and a few residents regarding the staffing levels and these were discussed with the manager. 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. DS0000069294.V345449.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 DS0000069294.V345449.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): 3 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents only move into this home following an assessment of their needs and an assurance that these will be met. EVIDENCE: Four resident’s files were sampled and each found to have had an assessment carried out by the home prior to admission. The admission template is set out with the same headings as the care plans e.g. personal hygiene, mobility, continence etc and the main findings of the assessment are then transferred to the care plan. All four assessments were completed in full and signed and dated by the person carrying out the assessment from Wykeham House. Those residents funded by the local authority also have care manager’s assessments, and some have health care assessments if they are jointly funded with health. DS0000069294.V345449.R01.S.doc Version 5.2 Page 10 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 and 10 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s care needs are set out in their individual plans, but more work is needed to ensure new residents have their assessments and corresponding guidance for staff completed as soon as possible after admission. Health needs are well catered for and the policies and procedures for the administration of medication safeguard residents. Arrangements for privacy and dignity are generally good but further improvements could be made. EVIDENCE: Four resident’s care plans were sampled. They are now in a standard format throughout the home and those examined were found to contain detailed guidance for staff on how resident’s care needs would be met. Each resident’s file contained a list of staff signatures at the front so that it would be easy to identify who had completed the various sections and the daily notes within DS0000069294.V345449.R01.S.doc Version 5.2 Page 11 each plan. All those plans sampled had been reviewed regularly every month and were properly signed and dated. Four residents were spoken with in some depth and all confirmed they were well cared for at this home. One resident who said he was very happy at Wykeham House added: ‘They do look after you.’ Staff were observed to be knowledgeable about resident’s individual needs and there were many examples throughout the day. For example the nurse giving medication placed the white tablets on a dark coloured napkin for one resident; the nurse explained this resident had a visual impairment and using the napkin meant that he could see them and pick them up himself. The manager is undertaking a 5 day course in dementia care and will be introducing person centred planning for those residents on Memory Lane by the end of the year. One resident who had been admitted some weeks ago still did not have a moving and handling risk assessment, nor a nutritional assessment on their file, and this was highlighted to the manager. One file did not have regular body mass index score on their weight chart, and this was also the only record were staff had not signed following each entry. A small number of concerns raised by a few relatives on their returned questionnaires were discussed with the manager for further action. There are arrangements in place to obtain healthcare support for residents including with local GPs, and an optometry service and podiatrist who visit the home. One healthcare professional returned a questionnaire to CSCI and noted that they had always found the level of care provided to be excellent, ‘..and they are very responsive to my suggestions.’ Community health professionals come into the home to provide staff training on specific topics, for example on medication, nutrition, and continence. In addition to ongoing personal care needs, resident’s files showed evidence of ‘short term care plans’ where a specific health problem was being monitored, for example a pressure sore, or injury following a fall. According to the AQAA, there were 11 residents who had developed pressure sores over the last 12 months and the manager outlined arrangements for the prevention, treatment and monitoring of these, including sending a monthly monitoring report to the clinical director. This work is ongoing and the manager was asked to ensure that CSCI were kept informed. One medication administration session was observed on High Beeches and the registered nurse explained the current arrangements. There is a medication policy in place and the home uses blister packs supplied by a local pharmacy. Three resident’s records were checked and found to contain a photograph of each resident, a copy of staff signatures, fully completed record sheets with no unexplained gaps, and handwritten additions were signed and countersigned. Medication cabinets and the trolley were well kept and secure. The last pharmacist’s report commented on the ‘high standard’ of medication DS0000069294.V345449.R01.S.doc Version 5.2 Page 12 administration at this home. There is also a regular internal medication audit carried out. There are arrangements in place to ensure the privacy and dignity of residents, and staff have recently had a training session on this subject. One resident who was on the ground floor had no net curtains at the window but said whenever staff were helping her with personal care, they always drew the curtains; she preferred not to have nets as she had a good view over the front of the house. Cordless telephones have been introduced which means residents can have the telephone brought to them if they receive a call, and can then take the call in private if they wish. None of the residents spoken with raised any negative issues in relation to privacy and dignity though a number of matters were raised by the inspector with the manager. One resident had fallen asleep following their lunch and had a considerable amount of food which they had spilled on their front – this should have been attended to by staff; another resident’s armchair had a pad left on the chair, even though they were not in it; and one sitting room had plastic bags covering the seat cushions of two chairs. The manager agreed that these matters affected the privacy and dignity of residents and rectified them immediately. DS0000069294.V345449.R01.S.doc Version 5.2 Page 13 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 and 15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are arrangements in place for activities and to enable residents to have contact with the local community. Residents are given some opportunities to exercise choice and control over their lives. Meals at this home are nutritious and offered in very pleasing surroundings. EVIDENCE: There is an activities programme in place and there are usually two activities co-ordinators for this home – the second post is vacant and the manager is recruiting a replacement. The manager said he has improved the activities programme to include at least one activity in the morning and another in the afternoon. There were some additional activities not listed on the programme, for example visiting dogs (and their owners) come to the home on a regular day each week and these were seen on the day of the inspection. Residents spoken with on the day of the inspection knew what activities were on, and those who didn’t, showed me the weekly activities programme; all residents receive their own copy. The Memory Lane Unit is furnished with a number of DS0000069294.V345449.R01.S.doc Version 5.2 Page 14 reminiscence items and the décor is very pleasing and suitable for those residents with a memory impairment. The manager realises there is more work to be done regarding activities, particularly activities for people with dementia and he intends to dovetail this work with the person centred planning project to start later in the year. He was also asked to ensure that those working with people with dementia had some training in activity provision, and in particular that at least one of the activities co-ordinators should have some specialist training. There are some opportunities for community contact at this home and friends and relatives are made welcome. Those relatives who returned questionnaires said that the home kept them in touch with what was happening with their friend or relative. The home also has a relatives meeting and the manager was able to demonstrate how some of the suggestions made at these meetings had been followed through. Residents use the health services available in the local community, including the GP, community matron, podiatrist and optometrists. Staff also benefit by training provided by local health professionals. There are also some entertainers visiting from the local community, including one gentleman who plays the piano, and the ladies who bring their pet dogs. Residents are offered some opportunities to exercise choice and control over their lives and throughout the inspection residents were heard to be given choices and on some occasions given extra time and support to come to a decision. The company has commissioned a private advocacy service and pays them a retainer to offer advice on benefits and entitlements, and paying for care to any resident who wishes to use that service. The manager said all current residents now have either a relative or a friend who supports them and therefore no other advocacy input is needed. Residents are allowed to bring personal possessions with them and all the bedrooms visits showed evidence of this including ornaments, photos, models, and paintings. Each of the resident’s files sampled showed a list of their personal possessions had been made when they first moved into the home. Residents commented positively on the food at this home and the dining areas were particularly well furnished and pleasant with printed menus on each table. Both dining rooms were visited at lunchtime. In High Beeches, residents with serious mobility problems, including not being able to sit up in a straight backed chair, were still accommodated in the dining room and there were plenty of staff on hand to assist. The dining area in Memory Lane was also pleasant though during the meal itself there were a number of minor issues highlighted to the manager including the radio playing in the background which was a bit loud and distracting, and unlikely to have been playing the station chosen by residents. In the living room opposite one resident was sitting with a cold dinner (this point was also made on a questionnaire from a relative), and another had spilled some food – both these residents needed DS0000069294.V345449.R01.S.doc Version 5.2 Page 15 some support but the only member of staff in the room was feeding a third resident. The manager dealt with these matters straight away. On the day of the inspection the main course was pork chop with apple sauce, roast and creamed potatoes, mashed swede and cabbage, followed by a sponge pudding. All those spoken to in both dining rooms (who were able to comment) said they enjoyed their meal and that the food at this home is good. The inspector tasted a teaspoon of each item served as the main course and found the food to be well cooked and very tasty. DS0000069294.V345449.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 and 18 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously at this home and residents are protected from abuse. EVIDENCE: The home has a complaints procedure in place and this is displayed in the home where residents and visitors would be able to see it. No complaints have been received to CSCI about this service since the last inspection. As this service re-registered with CSCI in February 2007, complaints records from this date were checked at the home. A few have been received but these have all been properly noted and satisfactorily concluded. The home has a copy of the local procedures for safeguarding vulnerable adults and their own arrangements in place to ensure the safety of residents. The manager carries out the training and refresher courses for staff on this subject and, though there is not yet a central training list, he stated that all staff have received training on this area. No reports have been made to CSCI on safeguarding matters at this service since the last inspection. On the day of the inspection a new member of staff who had transferred from another home within the company had been invited in to start their induction DS0000069294.V345449.R01.S.doc Version 5.2 Page 17 on the computer in one of the Units. The CRB had been applied for but a satisfactory pova check had yet to be carried out. Even though this involved only limited direct access to residents, it is not recommended for new staff to be allowed into the home until the Povafirst check has been completed. Following a satisfactory check, staff can then only work in the home, under supervision, and as set down in the Care Homes Regulations 2001 (as amended). The manager carried out a risk assessment and this was faxed to CSCI. DS0000069294.V345449.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 and 26 People who use the service experience Adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. This home offers a very pleasant and clean environment though some more work is needed to meet these Standards in full. EVIDENCE: This home is very nicely furnished and decorated and residents spoken to were pleased with their rooms and other facilities. The entrance is welcoming and the communal areas are comfortable and spacious. The gardens are well looked after, including the front gardens and the car park. There are lovely hanging baskets and troughs of flowers for residents and visitors to enjoy. There is a programme of ongoing maintenance on repairs and a number of items highlighted to the manager on the day of the inspection were already on DS0000069294.V345449.R01.S.doc Version 5.2 Page 19 the list to be done. The kitchen has been refurbished since the last inspection. One resident asked for an extra chair for her room and the manager said he would organise this. The matters requiring attention highlighted to the manager included: • one bathroom was being used for storage of hoists etc; • the kitchen floor, most of which had not been replaced during the refurbishment, now looked worn and needed cleaning, particularly behind and under appliances; • there were some minor decorative matters including paint scraped of walls, probably where wheelchairs had been used, and a stained ceiling in one toilet following a leak; • the lights in some corridors needed cleaning as they had flies in. Arrangements for hygiene and the control of infection are in place and there were good hand washing facilities, with each basin having individually dispensed soap and paper towels available. The home employs domestic and laundry staff, and the majority of areas in the home were fresh and clean. The laundry was tidy and well-organised, with separate containers for each resident’s clean laundry. Machines are the commercial type, with sluicing facilities on the washing machines. The coloured bag system is used to separate the various items of coiled laundry. However, some toilet areas had slight odours, and the laundry itself had a leak behind one of the machines; the area behind the machines also needed a good clean. One of the containers attached to pipes feeding the machines was nearly empty and another container of peroxide had been placed beside it (with a lid on) ready to swap over. As the laundry itself is not locked when unattended, the manager was asked to review the safety aspects of this practice. There was also no alcohol hand-gel available in the home, despite some residents having infections requiring extra vigilance. Though hand washing facilities were good, it is recommended that the home review their practices and guidance for staff with regard to the control of infection. The home’s policy was viewed but did not give sufficient detail to guide staff. The manager spoke with a senior person concerned with clinical arrangements at head office and will be reviewing current practices in the light of this advice. DS0000069294.V345449.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 and 30 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s needs are now being better met by the numbers and skill mix of staff but more work needs to be done. Residents are in safe hands. Recruitment practices are good. Staff training arrangements are improving. EVIDENCE: There is a recorded staff rota in place and since the last inspection the manager has reviewed staffing numbers and increased staff as follows. Memory Lane has 6 care workers plus two qualified nurses in the morning and the afternoon, up from 5 care workers. And High Beeches has 7 care workers in the morning and 4 in the afternoon, plus 2 RGNs on each shift. The change there has been that there is an extra RGN rather than just one on each shift. In addition there are kitchen, laundry and domestic staff employed at the home. The inspector noted that one call bell in the afternoon took many minutes to answer, and that one dining area needed more staff over the lunch period. Some relatives and one resident commented on staffing numbers on their questionnaires returned to CSCI and this was discussed with the manager. The manager said he is keeping the number and the deployment of staff under review. DS0000069294.V345449.R01.S.doc Version 5.2 Page 21 The manager identified in the AQAA returned to CSCI that a training needs matrix was still required though there was evidence that the data needed to complete this had already been collected in hand-written form. The manager had found the staff qualification section of the AQAA confusing and numbers were confirmed with him during the inspection, and with the administrator on the telephone whilst the report was being written. In addition to 17 trained nurses, there are 20 domestic staff and 35 care staff. Of the 35 care staff, 11 have a nursing qualification from abroad and 2 have an NVQ Level 2. This means only 13 of the 35 care staff have a qualification and this falls short of the 50 recommended in the National Minimum Standards. However, 3 more people have recently signed up for NVQ Level 2s, and the manager aims to get another 3 signed up by the end August. Recruitment arrangements at this home are good with staff files being wellorganised and all the necessary recruitment checks being on the two files sampled. This included an application form, photographic identification, two references, and CRB clearance. The file sampled for a member of staff who started after July 2004 when the Regulations changed, also had a full employment history on their application. The issue regarding a new member of staff without a Povafirst check was discussed under Standard 18. There is a programme in place to ensure all new staff go through an induction course, and those sampled were correctly signed off as complete. The manager confirmed the company’s induction was based on the Skills for Care Common Induction Standards, which also dovetails with NVQ qualifications for those staff who wish to gain a care qualification. Staff at this service receive in excess of three paid training days per year as set down in Standard 30. There are training certificates on file but more work is being done on a training matrix and central record of staff training. One member of staff interviewed identified a number of ways in which the company ensured staff were trained to do their jobs, and he had done three courses relevant to the administration of medication for example. He said specialist training was available if necessary, for example if specialist equipment was needed for a particular resident. Staff at this home are due to go on an equality and diversity training course and the manager said he has booked the first group in for later in August. DS0000069294.V345449.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 and 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home, with good quality assurance processes in place. Resident’s financial interests are safeguarded. Health and safety arrangements are in place but more work needs to be done to meet this Standard in full. EVIDENCE: The registered manager has been in post since 2003. He is responsible for no more than one registered establishment and attends periodic training to keep his own knowledge, skills and competence up-to-date. There are clear lines of accountability within the home and externally with the company. The manager DS0000069294.V345449.R01.S.doc Version 5.2 Page 23 is assisted in the day to day administration by the home’s Administrator, who has an NVQ Level 3 in Business Administration. Arrangements are in place for quality assurance processes to measure the quality of the service provided at Wykeham House and there is a specific policy on quality assurance processes. There are annual questionnaires for residents, regular meetings for residents and relatives, and Regulation 26 visits to this service by the provider. There are other measures in place to monitor the quality of what is being provided, for example monthly pressure sore monitoring reports, a health and safety audit, activities audit, and a professional practice audit. There has also been a quality assurance audit in July 2007. The manager mentioned in the AQAA document, and during conversations during the day, how changes had come about due to receiving feedback from residents and other stakeholders. The manager said this home does not get involved with managing resident’s finances and where individuals are unable to do this themselves, they are assisted by relatives, or else legal arrangements have been made to do this formally, i.e. with solicitors. Resident’s newspapers and other bills are paid by the home and then the resident is invoiced once a month. Some residents keep their own money and each has a lockable facility in their room. There are arrangements in place to manage health and safety within the home and evidence of a health and safety audit being carried out. Water safety is overseen by the maintenance worker who carries out the regular checks and the home has a certificate from the Legionella Control Association, valid until 31st August 2007. Those radiators seen by the inspector had covers in place, and three water outlets were tested in resident’s bedroom and all found to be within acceptable limits. The environmental health department visited the home 9 months ago and made a number of requirements; the chef and the manger agreed that these requirements have now been met. Other certificates and documents were sampled including the electrical appliance testing certificate, for tests carried out in September 06, and the employers liability insurance, to June 2008. A number of health and safety matters arose during the day, and Immediate Requirements were made. The first being the garden shed which was left open. A number of liquids in the shed could have been hazardous in the wrong hands and the manager locked the shed immediately. The indoor cleaner’s cupboard was found to be shut but not locked and again this contained substances which may have been hazardous. A nurse went to get the keys and locked the cupboard immediately. There was a also some peroxide in the laundry which had a lid but had not been fitted to the tubing behind the washing machine, and this could have posed a threat in the wrong hands. The laundry door is not locked and the manager was asked to review these arrangements. None of the above hazards would have been accessible to those DS0000069294.V345449.R01.S.doc Version 5.2 Page 24 residents with dementia, as they are in their own unit with a separate secure garden. DS0000069294.V345449.R01.S.doc Version 5.2 Page 25 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000069294.V345449.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 OP7 Regulation 14(1)(a) 15(1) Requirement Timescale for action 10/08/07 2. OP19 23(2)(b) 3. OP26 16(2)(j) Resident’s files must contain all the necessary information including moving and handling and nutritional risk assessments, as discussed during the inspection. The issues highlighted under this 10/09/07 Standard need to be reviewed and dealt with including: one bathroom used for storage of hoists; the kitchen floor which is very worn; paint scraped of some walls; a stained ceiling in one toilet; and the lights in some corridors needed cleaning. The issues highlighted under this 17/08/07 Standard need to be reviewed and dealt with including: the leak behind one of the machines in the laundry; the area behind the machines also needed a good clean; there were odours in some bathroom/toilet areas; arrangements for replacing laundry liquids could potentially pose a hazard; and there is no alcohol hand-gel available in the home, nor clear guidance for staff on this matter. DS0000069294.V345449.R01.S.doc Version 5.2 Page 27 4. OP38 13(4)(a) Arrangements for health and safety, in particular the security of areas for storing potentially hazardous substances, must be reviewed to ensure the safety of residents. 10/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP10 Good Practice Recommendations Arrangements should be reviewed to ensure that the privacy and dignity of residents are maintained and promoted at all times, including making sufficient support available at lunchtimes. Specialist training in provision of activities for people with dementia should be made available to staff, especially those whose main role is to co-ordinate the home’s activities. 2. OP12 DS0000069294.V345449.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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