Inspection on 30/03/05 for Wymondley Nursing Home

Care Home For Older PeopleWymondley Nursing HomeWymondley Nr Hitchin Hertfordshire SG4 7HTUnannounced Inspection30th March 2005 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 25th May 2004 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 330th March 2005 10:30 am Mr Tom CooperID Code076615Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionJoanne Kendell (Manager)Wymondley Nursing HomePage 2 CONTENTS Introduction 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. 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 August 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 a passenger lift. 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 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 very positive unannounced inspection at which the home was found to have resolved all the matters arising from the announced inspection last year and much evidence of forward progress was presented, especially in respect of the premises and provision of activities. The proprietors, manager and staff evidently work well together as a team. Service users spoken with expressed general satisfaction with life in the home. 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 with extensive documentation available for inspection. Staff appeared to relate well to service users and demonstrated good knowledge of individual needs. All the required information regarding the operation of the home, including the complaints procedure, is detailed in the Service User’s Guide issued on admission. Health and Personal Care (Standards 7-11) 5 Standards were assessed 5 were met The home maintains good relations with the local surgeries where service users are registered and specialist support is sought as necessary. Appropriate procedures are in place for the handling and recording of medication. All service users seen appeared well cared for. Daily Life and Social Activities (Standards 12-15) 4 Standards were assessed 4 were met Good progress has been made in developing the activities programme, based on the personal preferences of service users. A recommendation has been made to recruit a designated activities coordinator. Complaints and Protection (Standards 16-18) 3 Standards were assessed 3 were met The home has an adequate complaints procedure. No complaints have been received since the last inspection. Ancillary staff have been given abuse awareness training. Environment (Standards 19-26) 8 Standards were assessed 8 were met The premises were in good condition and clean throughout. Many improvements to the premises have been put in place since the last inspection including new hospital beds, laundry equipment and lighting.Wymondley Nursing HomePage 6 Staffing (Standards 27-30) 3 Standards were assessed 3 were met There is a large staff team at the home, including many individuals who have worked at Wymondley for a number of years. Adequate staffing levels were being maintained. Improvements had been made to the staff records, with evidence of staff training and CRB disclosures now available for inspection. Management and Administration (Standards 31-38) 7 Standards were assessed 7 were met The manager has been in post for a number of years and is experienced and competent. The home had a very friendly ambience on the day of the inspection. All the records inspected were in good order. All the health and safety issues raised at the last inspection had been rectified. Service users are consulted for their views on the running of the home.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 None.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 None.Conditions of registration that apply (other than numbers and category of service users). Wymondley Nursing HomeMet (Yes / No) Page 7 There are no additional conditions ofregistration.STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION 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 None.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 OP 12 An appropriately skilled activities coordinator should be employed.* 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 8 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 NO YES YES YES YES NA YES NO YES NO YES YES YES NO NO YES NO YES 8 1 0yeNO NO YES YES 41 17 30/03/05 10.30 4Wymondley Nursing HomePage 9 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 10 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 (£) 533 To (£) 593Any charges for extrasYESPersonal Items If yes, please state what the extras are: 3 Key findings/Evidence Standard met? The company has a Statement of Purpose and Service User’s Guide containing the information required by the Care Homes Regulations 2001. The manager and directors stated that the Service User’s Guide is issued to service users upon admission thereby ensuring that the operation of the home, complaints procedure and so on are properly publicised.Wymondley Nursing HomePage 11 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 home’s policy is for the manager to carry out a pre-admission assessment for a prospective service user. The assessment form includes details such as mobility, continence needs, nutritional requirements and social needs. For individuals referred through adult care services care management arrangements, the social worker’s assessment would be considered as part of the home’s assessment process. The manager would also consider the likely compatibility of the prospective service user with the existing group of residents. 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? The inspector observed positive interactions between service users and staff, indicating that staff individually and collectively have the skill and knowledge to care for the client group. External specialists are contacted when needed as well as advice from Macmillan nurses and community psychiatric nurses etc. depending on individual service users’ needs.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 make short visits to the home, which would include having lunch and meeting residents, before making the decision to move into the home. The offer of a permanent place is subject to a four week trial period that may be extended by mutual agreement.Wymondley Nursing HomePage 12 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.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? Care plans were in place for all service users, developed from the initial admission assessment, covering most aspects of daily life and nursing needs. Social histories are also included, which give staff an insight into the lives of the service users before they entered the home.Wymondley Nursing HomePage 13 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) 0 03 Key findings/Evidence Standard met? All accidents are recorded and details of all accidents or incidents affecting the health and welfare of service users are forwarded to the CSCI as required by regulation. The home maintains good relations with the local surgeries where service users are registered; one GP visits the home regularly and holds 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.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 is stored in two locked metal trolleys, one for service users on the ground floor, the other for those on the first and second floors. All the prescription information on medicine containers checked matched that on MAR sheets. The home uses a practical orange sticker system to alert staff to changes of prescription made by doctors.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 service users seen were appropriately dressed and well groomed, with attention paid to nail care and hairdressing. Staff ensure that any medical examination or treatment is carried out in the privacy of the service user’s bedroom. In line with the home’s policy, staff were observed knocking and waiting at bedroom doors before entering. Service users spoken with said that staff used their preferred terms of address.Wymondley Nursing HomePage 14 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? The home has policies covering how to deal with dying and death and a policy for staff to follow after the death of a service user. Time would be allowed for family and friends to pay their respects. The manager is aware of the importance of ensuring that the service user’s wishes concerning spiritual needs, rites and functions are observed as documented in the personal file.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. 3 Key findings/Evidence Standard met? At the time of the inspection the home did not employ an activities co-ordinator, although the manager had identified a potential candidate for the role. Following the requirement made in the last inspection report, there was evidence that good progress had been made in developing a structured activities programme. Initially, keyworkers consult individual service users and/or relatives to ascertain what they would like to do and their preferences are noted on specific lists held on their personal files. The manager then uses this information to create a formal activities schedule that also lists the names of service users wishing to participate in the various events. These include bingo, scrabble, skittles, card games, flower arranging, arts and crafts, quizzes, manicures and so on. The inspector and manager discussed the value of having a specifically designated person to sustain and expand the activities programme and a recommendation to that effect has been made in this report. During the inspection a group of service users were enthusiastically playing cards and examples of craft items recently made for Easter were displayed on the premises. Service users spoken with expressed general satisfaction with life in the home although several said they were not interested in participating in activities.Wymondley Nursing HomePage 15 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.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. The inspector saw numerous personal items in individual bedrooms. 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? The well-balanced and varied menus are changed every month. Special diets are catered for. With only one exception, service users said the food provided was very good. The dining room is large and well set out. Since the last inspection a ceramic tile floor has been laid in the dining room. Before proceeding, the proprietor took advice from the Health and Safety Executive regarding the safety aspects of this type of flooring, which is much easier to keep clean than the previous carpet.Wymondley Nursing HomePage 16 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 3 Key findings/Evidence Standard met? The complaints procedure contains all the details required by the Care Homes Regulations 2001. The manager and proprietor stated that all service users had access to this document, which is contained in the Service User’s guide. Residents spoken with had varying awareness of the procedure, however given the memory problems many elderly service users suffer from that was not indicative of any failure on the part of the management to publicise it.Wymondley Nursing HomePage 17 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 would be able to vote by post in the forthcoming general election. Reportedly, local MPs visit the home from time to time.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 X3 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. As recommended in the last inspection report, ancillary staff had been given awareness training on this topic and records were available for inspection.Wymondley Nursing HomePage 18 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 and equipped to meet the needs of elderly people with the mobility problems associated with advanced old age. There is ample communal space in the home, including are several seating areas and a large dining room. There are designated areas for smokers. The home also has attractive landscaped gardens with ample seating areas and furniture. At this inspection there was considerable evidence of improvements to the premises. For example, on the day of the inspection landscaping work was in progress to upgrade the grounds; several new magnetic fire door clasps had been installed since the last inspection (no doors were wedged open or obstructed); the proprietor stated that a large number of new adjustable hospital beds had been purchased and there were now only four ordinary beds left in the home; two new dryers had been purchased for the laundry. See also standard 25 with reference to new overhead lighting.Wymondley Nursing HomePage 19 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.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 are several assisted bathrooms throughout the building with sophisticated modern lifting equipment installed. The sluices are located separately from toilets and bathrooms. All areas seen were clean and uncluttered. Many of the bedrooms have en-suite facilities.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. 3 Key findings/Evidence Standard met? 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. These allow for safe moving and handling practice under all circumstances. The call system was seen to be in working order. Two new storage areas have been built for commodes and therefore the requirement made in the last inspection report has been complied with. All the bathrooms were clear and available for use.Wymondley Nursing HomePage 20 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 is met. YES NO NO 59 22 0 0 Standard met? 3 59 XX 0 0 0Wymondley Nursing HomePage 21 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? All bedrooms seen during the inspection were furnished with good quality furniture and fittings. Many of the bedrooms have en-suite facilities and upper storey rooms have very pleasant views over the North Hertfordshire countryside. 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. 3 Key findings/Evidence Standard met? The home is centrally heated and was comfortably warm on the day of the inspection. Radiators are safe and can be individually controlled. During 2004 all the overhead lighting in the building was replaced after a risk assessment prompted by a minor fire in one light unit (notified to the CSCI). The premises are light and airy, with particularly good natural daylight available through overhead skylights and in the central lounge area. There is also adequate lighting in service users’ bedrooms. The proprietor stated that a legionella test had been carried out on the water system within the last five years. Hot water was always stored and circulated at safe temperatures. 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 its collection. There are good hand-washing facilities for staff and service users. Disposable gloves and aprons were available in all areas for staff use. The inspector toured the building and noted that all areas, including the kitchen, were clean and free from unpleasant smells.Wymondley Nursing HomePage 22 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. This guidance does not apply to homes registered before April 2002. 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 Key findings/Evidence 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? 3Wymondley Nursing HomePage 23 On the day of the inspection there were three trained nurses and eight care assistants on duty. The manager was covering a gap caused by the short notice sickness of a trained nurse. The staff rota indicated that this was the typical picture from day to day. Adequate numbers of domestic and kitchen staff were on duty. These staffing levels are considered adequate to meet the needs of the 59 residents. The manager explained that because staff hours are generally made flexible to suit the needs of staff the home is very successful at recruitment and retention and can cover shortfalls due to annual leave and sickness in-house. As a result, no agency staff are used, with obvious benefits for the continuity of care to residents. 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 Key findings/Evidence Not inspected on this occasion. X X Standard met? 0Standard 29 (29.1 – 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? This standard was not fully inspected at this unannounced inspection, however evidence was seen that a rigorous recruitment procedure was being operated. Two written references are always taken up. Some staff files were sampled to check for evidence that CRB disclosures had been obtained prior to employment and several examples were seen. Also, following up a requirement from the last inspection, files were checked for evidence of staff training and qualifications. Suitable documentation was now being held on file to provide the evidence to meet the standard.Wymondley Nursing HomePage 24 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. 0 Key findings/Evidence Standard met? This standard was not fully inspected. However, following a requirement made in the last inspection report, the inspector checked the basic food hygiene certificates for all kitchen staff, as evidence that the requirement had been satisfied.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 well qualified, competent and experienced to run the home. She is undertaking the Registered Manager’s 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? Staff spoken with said that they had confidence in the approachable management team and felt well supported. There was a relaxed and friendly atmosphere in the home during the inspection. The manager and the two directors are constantly in the home and meet with staff and service users on a daily basis. Evidently this produces effective communications and teamwork. Wymondley Nursing Home Page 25 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. 3 Key findings/Evidence Standard met? The manager distributes questionnaires to canvass the views of service users, relatives and other interested parties. Staff, especially keyworkers, also ask service users directly what they think. The management team then consider the information when planning how to improve the service.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. 3 Key findings/Evidence Standard met? Adequate insurance cover is in place. The proprietor stated that stated that there were no formal budgets for the home as the company’s policy was to provide services and equipment based on identified need rather than restrictive financial models. The company’s accounts would be made available for inspection by the CSCI on request. However the home has consistently achieved full occupancy over an extended period, the premises are very well maintained and equipped and no agency staff are used. Therefore there is no evidence of any problem with financial viability. 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 XWymondley Nursing HomePage 26 Standard 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.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. 3 Key findings/Evidence Standard met? This standard was not fully inspected at this unannounced inspection. However, all records seen were generally up to date and accurate, including medication records. Service users’ personal files now include a record of furniture or other items brought into the home, thus satisfying the requirement made in the last inspection report.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. 3 Key findings/Evidence Standard met? All areas checked were satisfactory. During the tour of the building the inspector noted that all rooms where potentially dangerous or hazardous substances were stored were kept locked. No liquids or cleaning products were left unattended. Mandatory training was being kept up to date.Wymondley Nursing HomePage 27 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition 1.ComplianceYESThis home may accommodate up to 4 older people who require personal care.CommentsCondition 2.ComplianceYESThis home may accommodate up to 3 older people with dementia who require personal care.CommentsYES Condition Compliance 3. This home may accommodate 59 older people who require nursing care. CommentsWymondley Nursing HomePage 28 Condition 4. 5. 6.ComplianceYESThis 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 convalescent nursing care.CommentsLead Inspector Second Inspector Regulation Manager Date Public reportsTom CooperSignature Signature SignatureIt should be noted that all CSCI inspection reports are public documents.Wymondley Nursing HomePage 29 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 30.03.05 and any factual inaccuracies:Please limit your comments to one side of A4 if possibleWymondley Nursing HomePage 30 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. D.2 Please provide the Commission with a written Action Plan by , 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. 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 31 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 32 Wymondley Nursing Home / 30th March 2005Commission 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.V215528.R01© This report may only be used in its entirety. 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