Inspection on 02/08/05 for Wymondley Nursing Home

This inspection was carried out on 2nd August 2005.

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

Wymondley Nursing Home 11/10/07

Wymondley Nursing Home 10/10/06

Wymondley Nursing Home 28/02/06

Wymondley Nursing Home 30/03/05

Wymondley Nursing Home 25/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Wymondley Nursing Home Wymondley Nr Hitchin Hertfordshire SG4 7HT Lead Inspector Louise Bushell Unannounced 02.08.05 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 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. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Wymondley Nursing Home Address Wymondley Nr Hitchin Hertfordshire SG4 7HT 011438 312434 01438 355659 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Wymondley Nursing and Residential Care Home Limited Ms Joanne Kendell Care Home 59 Category(ies) of DE DE(E) Dementia - over 65 - 3 registration, with number of places OP OP Old Age - 59 PD(E) PD(E) Physical Disability - over 65 - 59 TI(E) TI(E) Terminally Ill - 59 Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: This home may accommodate up to 4 older people who require personal care. This home may accommodate up to 3 older people with dementia who require personal care. This homemay accommodate 59 older people who require nursing care. This home may accommodate 59 older people with physical disability who require nursing care. This home may accommodate 59 older people with terminal illness who require nursing care. This home may accommodate 59 older people who require convelescent nursing care. Date of last inspection 30.03.05 Brief Description of the Service: The building is a former vicarage with a large modern extension. The provider, Wymondley Nursing and Residential Care Home Limited, was first registered by Hertfordshire County Council under the Registered Homes Act 1984 in March 1990 prior to the current registration under the Care Standards Act 2000. The home provides nursing care and accommodation for older people, with or without physical disabilities and for older people with terminal illnesses. It is also registered to provide personal care for 3 older persons with dementia. The home is situated in the village of Wymondley, close to the towns of Hitchin, Letchworth and Stevenage, a short distance from the village centre with facilities such as the church and pub. The home has links with organisations in the village. Access to public transport is limited.Accommodation is provided on three floors served by 2 passenger lifts. All bedrooms are single rooms, 22 with en-suite toilets. There are several day rooms. The building stands in extensive, attractive grounds, greatly enjoyed by many service users. There is ample car parking space in front of the home. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of this inspection year, taking place mid morning to late afternoon. This was an extremely positive inspection, reflecting the positive comments made by both service users and visitors to the home. Time was spent with the manager of the home discussing processes, policies and procedures including recruitment; training systems and service user care plans. The focus of this inspection was to seek the views and the opinions of the service users and visitors within the home, hence the majority of time was spent with the service users engaging in activities that were available and talking with them individually and within small groups. What the service does well: The environment within the home is maintained to a high standard with both internal and external decoration being well maintained and presenting a homely feel. The home provides 40 hours per week for maintenance and repairs to the home. All service users rooms are decorated to personal taste and all are encouraged to personalise their rooms. During the inspection the views of a visitor to the home was sought, many positive comments were made in respect of the home in general a visitor summed up the home as being “a wonderfully caring and compassionate source.” Many positive comments were received from the service users regarding the home, one stating that “the home provides excellent care, the staff are brilliant.” The home is set in wonderfully maintained parklands, the back garden area has recently been landscaped and a water feature is now a favoured centrepiece of many of the service users. The area is wheelchair accessible and many positive comments have been received regarding the grounds, which are enjoyed by many. The home provides a wide range of activities and employs a specific activity coordinator to work with service users. Currently there is a provision of 10 hours per week, but also external entertainers, in house library delivery and weekly communion. Feedback from service users confirmed the range of activities available and comments were received stating, “we always have fun and like the music and games.” Activity plans were available throughout the home; a form has recently been introduced for service users to express what activities they would like to be involved in. This appears to be effective and active on the care plans inspected. Supervision and appraisals are offered within the home and feedback from staff spoken to confirm that the process was effective and a useful tool. Records were well maintained for all staff. Agency staff are not used and there Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 6 is therefore a consistent staff team to ensure that service users needs are being met at all times. Staff were indirectly observed interacting with all service users appropriately, the team appeared person centred and focused on ensuring each service users individual needs were being met. There is an effective key worker and named nurse system in place, which ensures sound management of each service users care plans and social fulfilment. There is a sound referrals and assessment process in place which encourages and enables involvement of the service user throughout the process. Detailed initial assessments were seen on the service users file and direct feedback was sought from a service user who has recently moved into the home. One service users stated that “ the process could not have been made any easer, it was really effective, I was made very welcome, and all the staff are so kind.” What has improved since the last inspection? Following the last inspection a number of improvement have been made to the home. This includes redecoration to communal and individual areas ensuring the environment remains well presented and homely. A number of new specialist profiling beds have been purchased. The manager stated that they are gradually replacing all the beds to ensure that current and changing needs of the service users can be met. New over head ceiling hoists have been purchased and are now functional, thus further support the needs of the service users. Fundraising is continually occurring within the home to ensure that items can be renewed and replaced periodically to ensure a high quality provision of resources. The manager stated that recently a new washing machine and dishwasher had been purchased, and that the sluicing machines are being replaced in order to maintain a high level of good practice and management of infection control within the home. The back garden has recently been landscaped and is an excellent relaxing environment for service users; many positive comments were received regarding the grounds. These are extremely well maintained and presented. A wide range of activities is provided and a specific activity coordinator is employed to work with service users. Currently, 10 hours per week is provided as are external entertainers, in house library delivery and weekly communion. Feedback from service users confirmed the range of activities available and comments were received stating, “we always have fun and like the music and games.” Activity plans were available throughout the home; a form for service users to express what activities they would like to be involved in has recently been introduced. This appears to be effective and active on the care plans inspected. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 7 What they could do better: Following discussion with the manager it was determined that currently the home is in the process of developing and implementing a new induction programme for all new staff. This process will ensure that the induction process is in greater detail and encourages staff personal and professional developmental throughout, focusing in attaining foundation certificates and other core training at different stages of the induction process. Draft examples were shown during the inspection and appear, once functioning to be effective. The manager discussed the development of the internal systems to ensure that all core and refresher training occurs for staff as required. The manager discussed implementing a training matrix to evidence staff training received and certificates gained in an individual training record for each member of staff. The manager should ensure that a balance of internal and external training resources are sought, advice was given regarding Protection of Vulnerable Adults Training being provided through Hertfordshire County Council and the need for the home to ensure that this is provided for all staff. There is a need to ensure that all ancillary staff receive manual handling and Protection of vulnerable Adults training. Medication systems are robust with detailed policy and procedures available for all nurses and staff. There is a need to ensure that if hand-written entries are made to the MAR sheets on instruction from the G.P, then these must be signed by the person making the entry to ensure that there is a clear line of accountability for those instructions. There is a rolling programme of renewing and redecorating areas of the home. During the inspection the manager highlighted a few areas that they were aware required redecorating and carpets replacing. There is a need to develop a renewal and redecoration plan to ensure a cyclic programme occurs. This will also enable reflection on progress to be made, highlighting positive improvements made at any stage within the cycle. A number of risk assessments are in place, although it was identified that there is a need for the home to further develop the premises fire risk assessment. Advice and guidance was provided to the manager concerning the risk assessment and the details to be included; there is a need for this to be reviewed and signed. The risk assessment must be specific to the premises is intended for. Further risk assessments are currently being developed for equipment within the main kitchen, for example the potato peeler and other items such as the free standing fans located throughout the home and the new height adjustable beds. Where drinking water is provided within the home, suitable signs must be present identifying it as an approved source of water to drink. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 8 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. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4 & 5 All service users are provided with accurate and adequate information, visits and discussions prior to admission to the home, ensuring that they are empowered and encouraged to make informed choices about where to live. EVIDENCE: There is a detailed and comprehensive Statement of Purpose in place, providing sufficient information for all prospective service users, friends and relative and supporters. All service users are provided with the documents prior to admission and following review. The service user or representative and Registered Manager sign the document on agreement and admission to the home. Care records of service users were inspected and there was evidence of pre admission assessment of needs being carried out in each case. A copy of the pre admission assessment of needs of prospective service users is received for those who are funded by the Social Services and discharge letters from hospital, where applicable. The manager or a senior member of staff would carry out the home’s own pre admission assessment of needs of any referred service user. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 11 There is a comprehensive and holistic pre admission assessment of needs for people with dementia and for people needing general nursing care. This information is used to formulate an initial care plan on admission. The home provides nursing and personal care for older people, some of whom may have associated physical disabilities/illnesses and dementia. Staff members were observed to be interacting well with service users, demonstrating good skills and knowledge to meet the specific care needs of the respective clients’ group. Prospective service users are invited to look around the home. Relatives invariably visit prior to admission of their next of kin. The initial admission would be on a trial period for a mutually agreed length of time, which can be extended if need be. This allows the home staff ample opportunity to further assess the service user’s needs and to formulate a detailed care plan. Direct feedback was sought for a service user who had recently moved into the home. One service users stated that “ the process could not have been made any easer, it was really effective, I was made very welcome, and all the staff are so kind.” Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Service users have full assessments completed on their individual files, ensuring that an individual plan of care can be set out meeting individual needs. The home has a comprehensive medication policy and procedure guidelines, which supports in the safe administration of medicines, staff must sign all entries on the MAR sheets to ensure accountability. Service users feel that they are treated with respect at al times, ensuring that personal choices, preferences, privacy and dignity of each service users is individually tailored for. EVIDENCE: All service users care plans were generated from the pre admission assessment and provides the basis of care to be offered to the individual. All care plans detail specific actions to be taken by the staff to ensure all aspects of the service users health, personal and social care needs are met. All care plans are reviewed once a month to ensure monitoring and changing needs can be addressed. The plan is drawn up with the involvement of the service user as much as possible, care plans had been signed by the service user and or representative. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 13 All service users spoken with appeared well cared for clean. Self-care is promoted by staff where ever possible. Appropriate risk assessments and monitoring charts are in place to ensure an appropriate level of support is offered. The ethos of good practice within the home ensures that preventive and restorative care is provided. Specialist medical support and advice is offered to any service users who may require it. All necessary equipment is provided to meet service users needs. Following discussions with service users is was confirmed that the staff are very caring and supportive, encouraging them to make decisions about their lives with appropriate assistance provided. Service users commented that they felt respected at all times. Privacy and dignity was observed being upheld. There is an effective key worker and named nurse system in place, which ensures sound management of each service users care plans and social fulfilment. During the inspection the views of a visitor to the home was sought, many positive comments were made in respect of the home in general a visitor summed up the home as being “a wonderfully caring and compassionate source.” Many positive comments were received from the service users regarding the home, one stating that “the home provides excellent care, the staff are brilliant.” Medication systems and procedures were observed and appeared to be wellmanaged, effective safe and organised. Records were well maintained. Advice is sought from the pharmacist regarding polices and best practice. A sound relationship with the local pharmacy that they use has been created. There is a need to ensure that if hand-written entries are made to the MAR sheets, on instruction from the G.P, then these must be signed by the person making the entry to ensure that there is a clear line of accountability. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 All service users are supported to maintain family, representative and community links as they wish, thus empowering and encouraging them to maintain, respect, dignity and personal autonomy over choices in their lives. Wholesome, adequate, varied meals are provided presenting a well-balanced nutritious diet for all service users supporting them to maintain a healthy life. EVIDENCE: Daily activities are offered. Staff provide a wide range of activities and a specific activity coordinator is employed to work with service users. Currently, there is an establishment of 10 hours per week, but also there are external entertainers, in house library delivery and weekly communion. Feedback from service users confirmed the range of activities available and comments were received stating, “we always have fun and like the music and games.” Activity plans were available throughout the home; recently introduced is a form for service users to express what activities they would like to be involved in. This appears to be effective and active on the care plans inspected. Visitors and volunteers are welcomed and encouraged. A calendar of events was displayed and each month, large posters displaying specific activities are available This included singers, clothing parties, specific activities for festivities throughout the year, sing along, keyboard and songs, craft fairs, BBQ’s and quiz’s. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 15 Involvement in other local community events is encouraged; emphasis is give to autonomy and choice for the service users. Residents meetings occur regularly and minutes are typed and are placed on notice boards throughout the home. Service users views and opinions are expressed freely within the home and efforts are clearly made to ensure that service users maintain vital links, personal autonomy and choices. If further support and or advice is required in order to ensure freedom of choice for the service users the home is able to link with specialist advocacy services in the best interest of the service user. Wholesome meals are provided. Feedback provided by many service users was extremely positive regarding the choice and availability of foods. A four-week rolling menu is in place, which is seasonal. All service users can make and are empowered and encouraged to make choices over the meals and the foods they eat. Hot and cold drinks are available throughout the home. Lunch was observed and appeared to be unhurried and a calm atmosphere. The kitchen was extremely well organised with excellent recording systems in place. The entire kitchen was clean and well presented. Foods were appropriately labelled and placed with the fried and freezers. Stock rotation occurs in the dry food store, which is regularly cleaned. The head chef had recently consulted with all the service users regarding meals and choices available. Feedback received determined that changes would occur to the menu’s ensuring that service users choices, preferences and views were listened to and acted upon. The service users stated that they always receive a choice for meals within the home and that individual needs can be catered for. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home has a comprehensive complaints procedure in place, which ensures that the rights of all service users are maintained. Robust polices, procedures and training for staff is in place regarding abuse, to ensure all service users are protected. EVIDENCE: There is a comprehensive complaints procedure, which is on display throughout the home. The ethos of good practice ensures that all complaints are taken seriously and acted upon. The open management of the home encourages and empowers staff and service users to make complaints with effective resolution. The procedure includes clear time scales and is accessible to all. A record of all complaints is maintained. Service users and visitors spoken with stated that they were aware of the complaints procedure and would not hesitate in making their complaints known to the management. They stated that they felt confident that their complaint would be dealt with effectively. The home has its own Whistle Blowing procedure, which is displayed in various locations throughout the home and the Hertfordshire Adult Protection Procedure has been adopted. Staff members spoken had a clear understanding of the policy following further briefing in staff and team meetings. Management should ensure that a balance of internal and external training resources are sought, advice was given regarding Protection of Vulnerable Adults Training being provided through Hertfordshire County Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 17 Council and the need for the home to ensure that this is provided for all staff. There is a need to ensure that all ancillary staff receives manual handling and Protection of Vulnerable Adults training. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 ,21, 22, 23, 24, 25 & 26 The home is well maintained, equipped and furnished. All areas are safe, comfortable and homely. This ensures that service users are able to maximise their independence and live in a warm, suitable, caring environment. EVIDENCE: The home is well maintained, clean and tidy. A maintenance person is employed to work in the home, providing a total of 40 hours. This has ensured that the home has remained in good order throughout. There is a system of constantly renewing and redecorating areas of the home. During the inspection the manager highlighted a few areas that she was aware required redecorating and carpets replacing. There is a need for the home to develop a renewal and redecoration plan to ensure a cyclic programme occurs within the home, this will also enable reflection on progress to be made, highlighting positive improvements made by the home at any stage within the cycle. The home is very bright and airy, promoting an accessible safe space for all service users. Service users spoken to confirmed that they like the decoration of the home and feel that it is a homely calm environment to be in. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 19 Indoor and outdoor communal space is well decorated in crisp bright colours. The back garden has recently been landscaped and is an excellent relaxing environment for service users; many positive comments were received regarding the grounds. These are extremely well maintained and presented. The manager stated that there are plans to landscape the front of the grounds later this year. Communal indoor space provides lighting of a domestic style and a friendly homely atmosphere suitable for the needs of the service users. Bathrooms and toilet facilities are in abundance throughout the home, ensuring that they all suitably located for all service use, staff and visitors. Service users spoken to stated that there are ample toilet facilities available at all times. Specialist equipment is also provided in abundance, ensuring all identified needs can be met. Suitable grab rails and other aids are available throughout the home. A call point system is available and call bells are suitably located for all service users. The system allows there to be a call record maintained to ensure a reasonable response time is provided to all service users. Service users confirmed that any time they have to wait, if they require assistance, is reasonable. The home has a passenger lift to enable service users to have access to the 1st and 2nd floor or ground floor. All rooms are single and provide adequate and suitable en-suite facilities. Rooms are personalised and well decorated. All service users are encouraged to personalise their rooms to individual tastes. Laundry facilities are sited so that soiled articles are not carried through where food is prepared. Hand washing facilities are provided throughout the building and staff are actively encouraged to maintain good hygiene practices. Policies and procedures are in place for the control of infection through out the home. The manager stated that recently a new washing machine and dishwasher had been purchased, and that the sluicing machines are being replaced in order to maintain a high level of good practice and management of infection control. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 The home is suitably staffed to ensure that individual service users needs are met at all times. Staff appear appropriately trained ensuring service users are in safe hands at all times. Recruitment and selection polices and procedures are robust ensuring service users are protected. EVIDENCE: Staff were seen to be working in sufficient numbers to meet all service users needs. Staffing rota’s reflected that adequately trained staff are working at any time within the building. Service users confirmed that they feel their individual needs are met with staff that are adequately trained. Ancillary staff are employed in such numbers ensuring that the building remains well maintained and functions as a clean environment. Following discussions with a number of ancillary staff it is felt that training in the protection of vulnerable adults is required, due to their vital contact with service users. Following discussion with the manager it was determined that currently the home is in the process of developing and implementing a new induction programme for all new staff. This process will ensure that the induction process is in greater detail and encourages staff personal and professional developmental throughout, focusing in attaining foundation certificates and other core training at different stages of the induction process. Draft examples were shown during the inspection and appear, once functioning to be effective. The manager discussed the development of the internal systems to ensure that all core and refresher training occurs for staff as Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 21 required. The manager discussed implementing a training matrix to evidence staff training received and certificates gained in an individual training record for each member of staff. There is a sound recruitment and selection procedure in place, ensuring suitable checks have occurred on all staff for the safety and protection of the service users. Recent training has covered food hygiene, first aid, managing violence and aggression, manual handling, positive dementia care, malnutrition and dementia, skin and wound care and caring for a person with dementia. All training needs are identified in supervision and appraisals. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 & 38 The manager’s qualifications and style of operation of the home ensures that the home is run in the best interests of the service user. Health and safety issues are well maintained and managed ensuring that the welfare of staff and service users is protected. EVIDENCE: Feedback from service users determined that the management and the ethos of the home is positive. The manager displayed clear direction and leadership which both the staff and the service users were able to understand. Staff spoken to confirmed that they have supervision. There appears to be clear and effective system in place. All records required by regulation were available upon request and were held in accordance with the Data Protection Act 1998. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 23 A number of risk assessments are in place, but it was identified that there is a need for further development of the premises fire risk assessment. Advice and guidance was provided to the manager concerning the risk assessment and the details to be included, there is a need for this to be reviewed and signed. The risk assessment must be specific to the premises is intended for. Further risk assessments are currently being developed for equipment within the main kitchen, for example the potato peeler and other items such as the free standing fans located throughout the home and the new height adjustable beds. Where drinking water is provided, suitable signs must be present identifying it as an approved source of water to drink. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x 3 3 2 Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 25 No Are there any outstanding requirements from the last inspection? 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. 2. Standard 9 19 Regulation 13 (2) 23 (2) (b) Requirement All medication entires on MAR sheets must be signed and dated. The registered manager must ensure that renewal and redecoration continues. A clear programme is to be developed highlighting works completed and works planned. The registered manager must ensure that all staff receive appropriate training. Ancillary staff must adult protection and manual handling training. All members of staff receive induction training to NTO specification within 6 weeks of appointment to their posts, including training on the principles of care, safe working practices, the organisation and worker role, the experiences and particular needs of the service user group, and the influences and particular requirements of the service setting. The registered manager must ensure that risk assessments are completed and implimented for the potato peeler, free standing fans, profiling beds and a Timescale for action 31st August 2005 30th september 2005 3. 27 18 (c) (i) 30th October 2005 30th November 2005 4. 30 18 (1) (a) & (c) 5. 38 13 (4) 22nd September 2005 Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 26 detailed premisies fire risk assessment. Drinking water signs must be located at designated drinking water sites within the home. 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 27 Good Practice Recommendations Staff training files should contain a list and evidence of training , with details or copies of certificates for verification. Wymondley Nursing Home I52_s19630 Wymondley v233599 020805 stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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