Inspection on 25/05/04 for Wymondley Nursing Home

Care Home For Older PeopleWymondley Nursing HomeWymondley Nr Hitchin Hertfordshire SG4 7HTAnnounced Inspection25th May 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Wymondley Nursing Home Address Wymondley, Nr Hitchin, Hertfordshire, SG4 7HT Email address Name of registered provider(s)/company (if applicable) Wymondley Nursing and Residential Care Home Limited Mr Richard Kelsall, Mrs Josephine Marita Kelsall Name of registered manager (if applicable) Ms Joanne Kendell Type of registration Care Home No. of places registered (if applicable) 59 Tel No: 01438 312434 Fax No: 01438 355659Category(ies) of registration, with (number of places) Dementia - over 65 years of age (3), Old age, not falling within any other category (59), Physical disability over 65 years of age (59), Terminally ill over 65 years of age (59) Registration number I020000330 Date first registered Date of latest registration certificate 18th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply? Date of last inspection 19th February 2003 YES YES 9/12/03 If Yes refer to Part CWymondley Nursing HomePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 325th May 2004 09:30 am Anne McLaird Mrs M ByrneID Code104651Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMs J. Kendell (Manager)Wymondley Nursing HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s AgreementWymondley Nursing HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Wymondley Nursing Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings • Provider’s response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Wymondley Nursing HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Wymondley care home is a former vicarage with a large modern extension. It provides nursing care and accommodation for older people, with or without physical disabilities and for older people with terminal illnesses. The home is also registered to provide for personal care for 3 older persons with dementia. It was first registered with Hertfordshire County Council Inspection Unit in August 1990. It is owned by Wymondley Nursing and Residential Care Home Limited. It is situated in the village of Wymondley, close to the towns of Hitchin, Letchworth and Stevenage. It is a short distance from the centre of the village facilities such as the church and pub and there are links with organisations in the village. Public transport links are limited Accommodation is provided on three floors served by a passenger lift. All bedrooms are single rooms, 22 of which have en suite toilets. There are a variety of day rooms. The home has extensive, attractive grounds, greatly enjoyed by many service users. There are ample car parking facilities to the front of the home.Wymondley Nursing HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTOR’S SUMMARY (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This was a positive inspection in terms of the care offered to service users and generally there was positive feedback from service users and relatives who had responded to the CSCI comment cards. There was a good staff team, many of who had worked at the home for a number of years. Staff spoken to during the inspection said that the management supported them. Although this inspection was conducted on 25 May 2004 representations were made by the proprietor, which lead to a formal complaint against the Commission which lead to the withdrawal of the report. The investigation of the complaint caused substantial delays in the re-publication of the report. Choice of Home (Standards 1-6) 5 Standards were assessed 5 were met There was evidence that service users’ needs were assessed prior to admission to the home and staff members were able to demonstrate that they possess the required skills and knowledge to meet the assessed needs. Feedback from comment cards was that not all relatives and service users had access to the latest inspection report; the proprietor stated that this information was included in the service user guide, which was freely available. Health and Personal Care (Standards 7-11) 5 Standards were assessed 5 were met The home maintains positive links with the local surgeries where service users are registered and specialist support is sought where necessary. From the information received via the feedback cards of the 19 responses 16 service users stated that they felt well cared for, 3 stated that they sometimes felt well cared for. Daily Life and Social Activities (Standards 12-15) 4 Standards were assessed 3 were met Feedback from the comment cards supplied by relatives and service users indicated that they would appreciate more activities at the home and a requirement has been made. Visitors and friends are able to visit the home at any reasonable time. Complaints and Protection (Standards 16-18) 3 Standards were assessed 1 was met The home has a complaints procedure and policy. A recommendation was made to make the complaints policy and procedure should be made more accessible. Environment (Standards 19-26) 7 Standards were assessed 6 were met The home has ample communal space and a designated area for smokers. Bedrooms were personalised with pictures and possessions. Staffing (Standards 27-30) 3 Standards were assessed and 2 were not met Wymondley Nursing Home Page 6 Standard 28 is not fully applicable until April 2005. There is a large staff team at the home, many who have worked there for a number of years. Staff were able to meet the service users needs and were seen to be supportive and caring towards the service users. Management and Administration (Standards 31-38) 5 Standards were assessed 3 were met The manager has been in post for a number of years, she is experienced and competent to run the home. Requirements were made regarding some of the health and safety aspects of the home.Wymondley Nursing HomePage 7 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard Required actions Timescale for action Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard NoneCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). NoneMet (Yes / No)Wymondley Nursing HomePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard * Requirement Timescale for action 1 23(4)(c)(i) OP38 Fire doors must only be kept in the open position by a means approved by the Fire Safety Officer. A structured activities programme must be implemented in consultation with the service users Alternative storage areas must be found for the commodes stored in bathrooms. The registered manager must ensure compliance with the Food Safety Act by ensuring staff employed in food handling attend a basic food hygiene course. Documentary evidence of relevant qualifications is kept at the home. A record of furniture brought into the home must be maintained. Cleaning fluids must be safely stored. 25th April 2005 25th April 2005 25th April 2005 25th April 2005216(2)(n)OP12323(2)(l)OP22413, 16, 18OP38(2)519 (1) Schedule 2(4) 17(2) Schedule 4(10) 13(4)OP2925th April 2005 25th April 2005 25th April 20056OP377OP38Wymondley Nursing HomePage 9 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Refer to Good Practice Recommendations Standard * 1 2 OP16 OP18 That the complaints policy is made more accessible to service users and visitors. That ancillary staff receive training regarding the Whistle Blowing Policy* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Wymondley Nursing HomePage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling • Pre-inspection questionnaire • Records • Care plans / Care pathways • Meals • Activities • Other (Specify) ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES YES YES NA YES YES YES YES YES YES YES YES NO YES NO YES 11 0 0 NO NO YES YES 41 17 25/05/04 09.30 14Wymondley Nursing HomePage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable.Wymondley Nursing HomePage 12 Choice of HomeThe intended outcomes for the following set of standards are: • • • • • • 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.Standard 1 (1.1 – 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users’ guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the home’s service user’s guide. Range of fees charged From (£) Per week 508 To (£) Per week 568Any charges for extrasYESPersonal items If yes, please state what the extra’s are: 3 Key findings/Evidence Standard met? The home had produced a Statement of Purpose and Service Users Guide that contained the information required by the Care Homes Regulations 2001. Some comment cards completed by service users and relatives had stated that they had not had access to the most recent inspection report, the proprietor stated that a copy of the most recent inspection report is available at the home along with the Service Users Guide.Wymondley Nursing HomePage 13 Standard 2 (2.1 – 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? The statement of terms and conditions for one-service user was sampled during the inspection and was satisfactory.Standard 3 (3.1 – 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The manager stated that she would carry out a pre-admission assessment for a prospective service user. The assessment form had recently been updated and included details such as mobility, continence needs, nutritional requirements and social needs. Where the prospective service user had a care manager, that assessment would be considered as part of the assessment process. The manager would also assess the compatibility of the prospective service user with the existing group. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? There was good interactions between service users and staff observed by the inspectors, indicating that staff collectively has the skill and knowledge to care for the client group. Specialist services are contacted when needed. Advice from Macmillan nurses and community psychiatric nurses would be sought when needed.Standard 5 (5.1 – 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? Prospective service users are able to spend short periods at the home, which would include having lunch and meeting other service users before making the decision to move into the home on a permanent basis. Offer of a placement is subjected to a 4-week trial period or a longer period by mutual agreement.Wymondley Nursing HomePage 14 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home does not offer intermediate care.Wymondley Nursing HomePage 15 Health and Personal CareThe intended outcomes for the following set of standards are: • • • • • The service user’s health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. 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.Standard 7 (7.1 – 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? There was a care plan in place for all service users, the plan had been developed through the initial admission assessment and covered most aspects of daily life and nursing needs. It was pleasing to note that the home had included a social history for the service users, which gives staff an insight into the lives of the service users before they entered the home.Standard 8 (8.1 – 8.13) The registered person promotes and maintains service users’ health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 2 13 Key findings/Evidence Standard met? There was good recording of accidents and all accidents or incidents affecting the health and welfare of service users are forwarded to the CSCI, Hertfordshire Area Office. The home maintains positive links with the local surgeries where service users are registered; one GP visits the home regularly and hold a mini surgery. Hearing and sight tests are arranged when necessary and the home has a visiting Chiropodist. Pressure relief equipment and incontinence aids were seen to be in place.Wymondley Nursing HomePage 16 Standard 9 (9.1 – 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? There is a medication room on the ground floor, which is kept locked when not in use. Stock medication and controlled drugs are locked in wall-mounted cabinets in the medicine room. Medication in current use are stored in 2 locked metal trolleys, one serving service users on the ground floor and one for service users on the first and second floor. Following representations made by the proprietor it has been decided not to make any requirements in this standard. However, it remains important that the directions on medicine containers must correspond with the MAR (Medication Administration Record) chart.Standard 10 (10.1 – 10.7) The arrangements for health and personal care ensure that service users’ privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? All services users were appropriately dressed and attention paid to nail care and hairdressing. Any medical examination would be carried out in the service users bedroom. The home operates a ‘knock and wait’ policy. This was observed to be in practice.Standard 11 (11.1 – 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? There were policies that covered dying and death; there was also a policy that gave guidance for staff to follow on the event of a death of a service user. The manager stated that younger staff and staff that were new to the home would be supported with this aspect of care. The manager was aware of how to ensure that spiritual needs, rites and functions should be met.Wymondley Nursing HomePage 17 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: • • • • 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.Standard 12 (12.1 – 12.4) The routines of daily living and activities made available are flexible and varied to suit service users’ expectations, preferences and capacities. 2 Key findings/Evidence Standard met? The home does not employ an activities co-ordinator. The inspectors were shown a list of activities that designated staff would carry out during their shift, these included quizzes, walks around the grounds, and music. The home also brings outside entertainment into the home, on a regular basis. Feedback from service users and relatives comment cards highlighted the need for a programme of regular activities. Some service users spoken to on the day of inspection stated that they would enjoy more activities at the home, and although there was flower arranging on the day of the inspection, those service users spoken to were not aware that it had been included in the days activities. Staff spoken to stated that although they enjoyed carrying out activities with service users, they were frequently called away to help with other duties, so that this time could not be said to be exclusively set aside for the service users activities. A requirement has been made that the home implements a structured activities programme in consultation with the service users at the home. Standard 13 (13.1 – 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users’ preferences. 3 Key findings/Evidence Standard met? Relatives and friends are able to visit the home at any reasonable time. The manager stated there are visits to the local pub and garden centre.Wymondley Nursing HomePage 18 Standard 14 (14.1 – 14.5) The registered person conducts the home so as to maximise service users’ capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? There did not appear to be any restriction on service users movements around the home. Breakfast is served at times suitable to the service users, and relatives and friends are able to visit at any reasonable time.Standard 15 (15.1 – 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Service users were having their breakfast at the beginning of the inspection, they appeared to be unhurried and supported by staff where necessary. Menus are changed every month and special diets are catered for. There were a few negative comments regarding the food at the home but generally the meals were enjoyed. The dining room is large and well set out, there were plans to change the flooring in the dining room from carpet to ceramic tiles, the proprietor had taken advice from the Health and Safety Executive regarding safety aspects of this type of flooring. During this time, service users would be able to take their meals in any of the other communal spaces at the home.Wymondley Nursing HomePage 19 Complaints and ProtectionThe intended outcomes for the following set of standards are: • • • 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.Standard 16 (16.1 – 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 X X X X X X 2 Key findings/Evidence Standard met? There was a complaints procedure that contained all the details required by the Care Homes Regulations 2001. The manager stated that all service users had access to this document, which is contained in the Statement of Purpose. Feedback on some of the comment cards from service users and relatives was they were not aware of the complaints procedure. It was recommended that the complaints policy should be made more easily available to service users and relatives. On the day of inspection the home did not have a method to record complaints and any response made to them, this was rectified before the end of the inspection.Wymondley Nursing HomePage 20 Standard 17 (17.1 – 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? The manager stated that service users are able to vote by post, and that local MP’s visit the home on a regular basis.Standard 18 (18.1 – 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES X2 Key findings/Evidence Standard met? The home has a Whistle Blowing Policy and care staff spoken to during the inspection had a good understanding of the policy and procedure. However, some ancillary staff were not aware of the policy or what they should do in the event of witnessing any incident of abuse. A recommendation has been made that the ancillary staff should receive training in this area.Wymondley Nursing HomePage 21 EnvironmentThe intended outcomes for the following set of standards are: • • • • • • • • 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.Standard 19 (19.1 – 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users’ individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home is well laid out with ample communal space, one relative commented that there was not enough space in the lounge when they visited, but there are alternative areas that could be used for communal space. There are some areas in the home that are in need of repair and replacement carpet. The manager stated that bedrooms are decorated before a new service user moves in. There are several seating areas in the home and a large dining room. There are designated areas for smokers. The home also has attractive landscaped gardens with ample seating areas and furniture. Standard 20. (20.1 – 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users’ private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? This Standard is met.Wymondley Nursing HomePage 22 Standard 21 (21.1 – 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? There were several assisted bathrooms throughout the home with appropriate lifting equipment installed. Please refer to Standard 22 regarding storage in bathrooms. Many of the bedrooms are en-suite.Standard 22 (22.1 – 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 2 Key findings/Evidence Standard met? There appeared to be insufficient storage areas in the home for items such as commodes and wheelchairs. Recommendations have been made in the previous inspections that commodes should not be stored in bathing areas; they were still stored in bathrooms at this inspection. The proprietor stated that this shortfall would be addressed when a planned extension is built, it is required that until this work has been completed that commodes should not be stored in bathrooms. Handrails are fitted in corridors and grab rails in WCs. There are sufficient bath aids and mobile hoists in the home. The home has several ceiling hoists. The home also has portable hoists. The call system was seen to be in working order, two service users stated that they sometimes had to wait up to ten minutes for a staff member to answer their call bell. The call bell was tested during this inspection, staff answered promptly.Wymondley Nursing HomePage 23 Standard 23 (23.1 – 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence This standard was met. YES NO NO 59 22 0 0 Standard met? 3 59 XX 0 0 0Wymondley Nursing HomePage 24 Standard 24 (24.1 – 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? Bedrooms seen during the inspection were furnished with good quality furniture and fittings. Many of the bedrooms are en-suite and those rooms on the upper floors of the home have very scenic views. Where necessary adaptations and specialist equipment had been fitted in bedrooms. Service users are encouraged to personalise their rooms with pictures and possessions. Standard 25 (25.1 – 25 8) The heating, lighting, water supply and ventilation of service users’ accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 26 (26.1 – 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? Clinical waste is disposed of appropriately and the home has a contract for the collection of the waste. There were good hand-washing facilities for staff and service users. Disposable gloves and aprons were available in all areas for staff use.Wymondley Nursing HomePage 25 StaffingThe intended outcomes for the following set of standards are: • • • • 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.Standard 27 (27.1 – 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X Standard met? 0Key findings/Evidence Not inspected on this occasion.Wymondley Nursing HomePage 26 Standard 28 (28.1 – 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 X X 9 Key findings/Evidence Standard met? The home has a large number of staff that is trained to NVQ levels 2 and 3. This training is done through the University of Hertfordshire. The home manager is an NVQ assessor.Standard 29 (29.1 – 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? The home has a large staff team and it was stated that staffing hours are made flexible to suit the needs of the staff; this arrangement benefits the service users because the home does not need to employ agency staff. Staff files sampled during the inspection generally contained good recordings including two references, copies of birth certificates and passports. Staff contracts were not contained on the staff files and were not inspected on this occasion. Copies of certificates for relevant qualifications were not kept on staff records, the manager stated that staff keep them at home, it is a requirement that documentary evidence of relevant qualifications is kept at the home. There were no records on staff files of CRB checks having being carried out. During discussion with the proprietors it was found that they were of the understanding that they were not obliged to record the individual CRB numbers when they had received the CRB Disclosure forms and that they should destroy the records after they had checked them. This information was incorrect and it is recommended that the proprietors seek guidance from the Criminal Records Bureau regarding this issue.Wymondley Nursing HomePage 27 Standard 30 (30.1 – 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 2 Key findings/Evidence Standard met? Staff working in the kitchen stated that they had not received the Basic Food Hygiene training; a requirement has been made for all staff that handles food at the home receives this training.Wymondley Nursing HomePage 28 Management and AdministrationThe intended outcomes for the following set of standards are: • • • • • • • • 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.Standard 31 (31.1 – 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? The manager is qualified, competent and experienced to run the home. She is undertaking the Registered Managers Award and has managed the home for a number of years.Standard 32 (32.1 – 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? There was a relaxed and friendly atmosphere at the home during the inspection, staff spoken to during the inspection stated that they felt supported and that the manager was very approachable. The manager and the two directors are permanently in the home and meet with staff and service users on a daily basis. Standard 33 (33.1 – 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Wymondley Nursing HomePage 29 Standard 34 (34.1 – 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 35 (35.1 – 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Not inspected on this occasion. Standard met? 0 X X XStandard 36 (36.1 – 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? The home has a comprehensive set of policies and procedures. Formal supervision is in place. The manager supervises the qualified nurses who in turn supervise care staff. Records of supervision are maintained.Wymondley Nursing HomePage 30 Standard 37 (37.1 – 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? The records seen on the day of inspection were generally up to date.There was no record of furniture or other items brought into the home by the service users, a requirement has been made.Standard 38 (38.1 – 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? Several of the service users bedroom doors had been wedged open by devices that had not been approved by the Fire Officer. A separate letter of requirement has been sent to the provider regarding this issue. Cleaning materials were left unattended in two areas of the home and a requirement has been made.Wymondley Nursing HomePage 31 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Additional Conditions of Registration 1 2ComplianceYESThis 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 home may 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.3 456This home may accommodate 59 older people who require convalescent nursing care. CommentsLead Inspector Second Inspector DateAnne McLaird Mrs M ByrneSignature Signature SignatureRegulation Manager Helen PettengellPublic reports It should be noted that all CSCI inspection reports are public documents.Wymondley Nursing HomePage 32 PART DD.1PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 25th May 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleWymondley Nursing HomePage 33 Action taken by the CSCI in response to provider comments: Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 29th April 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. D.2 Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was requiredAction plan was received at the point of publicationAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here Wymondley Nursing HomePage 34 D.3PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Wymondley Nursing HomePage 35 Wymondley Nursing Home / 25th May 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000019630.V139110.R02© This report may only be used in its entirety. 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