CARE HOMES FOR OLDER PEOPLE
Wyncroft 16 Moss Grove Kingswinford West Midlands DY6 9HU Lead Inspector
Yvonne South Unannounced 13 September 2005 1.30pm
th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Wyncroft House Nursing Home Address 16 Moss Grove Kingswinford Dudley West Midlands DY6 9HU 01384 291688 01384 402260 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Exceler Healthcare Services Ltd Mrs Wendy Averall Care Home 40 Category(ies) of OP - Older People (26) registration, with number PD - Physcial Disability (6) of places TE - Terminally Illness (6) Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: There are no additional conditions of registration to those listed on the previous page. Date of last inspection 16th February 2005 Brief Description of the Service: Wyncroft House Nursing Home is located off the main Wolverhampton to Stourbridge Road, close to Kingswinford village and the local transport system. The two storey property has been extended from the orginal house and in parts retains much of its orginal character. The home is registered to offer nursing care to a maximum of forty older people of either sex. However two bedrooms have been taken out of use and therefore the service is currently offered to a maximum of thirtysix people, some of whom may have a physical disability and/or need palliative care. All bedrooms are for single occupancy (there are no en-suite facilities) and there are communal toilets and bathroom facilities with suitable equipment to assist with personal hygiene. Communal lounges and a dining room are also available. A shaft lift assists people to move between floors. There is an attractive enclosed garden that enables ease of access to those with mobility difficulties. Parking facilities are located at the side of the property. The home is owned by Asbourne Consolidated Group Ltd and managed by Mrs Wendy Averill. Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This routine unannounced inspection commenced at 1.30pm and lasted for three and three-quarter hours. Assistance was given by the registered manager, Mrs Averall. The inspector spoke to six residents, six relatives/visitors and four members of staff. A tour of the home was conducted and various records, policies and procedures were inspected. A pre inspection questionnaire was sent to the manager in July by the Commission for Social Care Inspection. The completed document was given to the inspector on the day of this inspection. What the service does well:
The welcome extended by the home is warm and helpful. Staff can be seen assisting the residents in a kindly and competent manner. The residents and their visitors say that the care is ‘excellent’ and the staff are ‘wonderful’. Two activities staff are employed and provide a wide variety of recreational interests and events. Support is given to the residents in groups or on an individual basis, according to preference and need. There is a strong commitment to training and a large number of the staff have NVQ qualifications and are first aid trained. The food is described as very good and this opinion is supported by many positive comments and praise received by the cook. The menus offer a wide choice which can be adapted to suit individual tastes, diets and needs. The residents’ bedrooms are all attractively decorated and furnished. Every room is furnished to meet the wishes and needs of the occupant and fitted with a washbasin/vanity unit, a staff call bell and a nursing bed. People are also encourage to bring personal furniture and treasures if they wish Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These standards were not assessed during this inspection. However the manager indicated in the pre inspection questionnaire that improvements were being made to the statement of purpose and the service users’ guide which were currently presented as one document. It is intended that these will now be separated into two documents. Copies will need to be sent to the Commission for Social Care Inspection when the work has been completed. Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These standards were not assessed during this inspection. Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These standards were not assessed in full during this inspection. However it was observed that the staff related well to the residents. They were observed talking to and comforting some people, laughing and joking with others. Two activities staff were employed and although one person was currently off sick residents continued to be stimulated and involved in their surroundings. A resident was being given a manicure by one of the activities staff and the manager showed the inspector a small allotment in the garden that was attended to by a resident. A large variety of recreational activities were provided and enjoyed. Visitors were welcome and there was a steady flow during the afternoon. A small shop was available in the home for purchases of items such as crisps and sweets. There was also a coffee machine in the dining room and jugs of juice and water were readily available. The manager confirmed that religious services were held in the home for those who wished to participate and the involvement of relatives and friends in all activities was welcomed. Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 11 The inspector spoke with 6 residents and 6 visitors. Although the communication with some residents was impaired the home was overwhelmingly praised for the high standard of care and the kindness of staff. The cook was very proud of his kitchen and the recorded compliments, which indicated that the residents regularly voiced their appreciation of the meals he provided for them. A varied menu was provided and information was displayed to informed residents and their visitors of the meals and choices on offer. Good records were maintained of the food provided. Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18 Residents and their supporters are given relevant information and encouragement to voice any concerns they may have and are confident that they will receive an appropriate response. Suitable staff are recruited and trained to provide care and protect vulnerable adults. Residents’ rights and financial interests are respected and protected. EVIDENCE: An acceptable complaints procedure was available in the reception area and the manager confirmed that everyone received a personal copy with their letter of acceptance that was sent out to them following an acceptable pre admission assessment. A record was maintained of complaints received. This indicated that two complaints had been received since the previous inspection and both had been handled appropriately. The manager said that as part of the quality assurance and audit procedures a regular audit was made of any complaints received and communicated to the head office. The manager said that the electoral roll was updated on a regular basis and the residents were able to exercise their right to vote in elections if they wished. Assistance was given by family or staff if required and desired. It was seen that information was readily available regarding advocacy services although none of the current residents needed to access these.
Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 13 Policies and procedures were available to instruct and guide staff in the protection of vulnerable adults. Everyone was checked by the Criminal Records Bureau and of the Protection of Vulnerable Adults Register prior to being appointed and all staff received training from the time they were appointed. The manager was able to give a good example that demonstrated that the procedures were implemented when necessary. Residents’ personal finances were managed appropriately. Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19-26 The residents live in a clean safe environment that is appropriately furnished and provided with specialised equipment to meet their needs for comfort and care. Personal and communal rooms are acceptable for their purpose. However the fitting of suitable door locks to bedrooms would increase the availability of privacy for residents to obtain when they wished. Infection control procedures are in place that reduce the risk of cross infection within the home. EVIDENCE: The home was observed to be spacious and suitable for its stated purpose. There was a programme of routine maintenance and renewal and although the manager said that this had slipped a little behind because of a staff shortage a new member of staff was soon to take up his post. The focus had lately been on matters related to safety but with the increase in available personnel other tasks, such as the cleaning of corridor carpets, would receive attention.
Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 15 The storage available for maintenance equipment was soon to be improved. This would release space in the home for other purposes. The frontage of the home had recently been improved and the area landscaped and a large amount of in-house decoration and improvements had been achieved despite staff shortages. Communal facilities were spacious, well decorated and furnished. The lighting generally was acceptable and that in the dining room had recently been improved. However the manager said that the results were disappointing and further improvement were in hand. Bathroom and toilet facilities were suitable for the residents and appropriate aids were provided. Sluices were provided in accessible situations throughout the home. The equipment in these rooms had recently been upgraded and the fire detection system had consequently been improved in response to the specialist advice received. A shaft lift was provided and suitable fitments that assisted residents with mobility difficulties were available. Staff call bells were fitted throughout and were heard to be in working order. Storage was available for large equipment and this provision was to be improved further. The bedrooms were seen to be of an acceptable size, well decorated and furnished. Each room had been personalised with pictures, photographs and ornaments according to the wishes of the occupants. Lockable storage was provided but none of the bedrooms were fitted with door locks. The manager said that residents were informed that they could have a lock fitted if they wished. The standard requires that private accommodation should be fitted with locks suited to residents’ capabilities and accessible to staff in emergencies. These locks should meet with the criteria agreed with the Fire Authorities for such situations. Ventilation, heating, and water provision was acceptable. The home was observed to be clean and comfortable. Liquid soap and disposable towels were available with personal protective equipment and disposal facilities as necessary. Relevant policies and procedures were seen. The laundry was well equipped and recently a new tumble dryer and steam generator had been provided. The room was clean and well maintained. Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30, The residents are care for by a team of suitably recruited and well-trained staff. EVIDENCE: Duty rosters were seen to provide an acceptable level of staffing with a suitable skill mix. The records of two recently appointed members of staff were inspected and were acceptable. There was a strong commitment to training. A training matrix was held on computer that indicated the achievements and needs of all staff. Dates for reviews were identified and actioned. Records were well maintained. The manager said that the situation was audited weekly and information provided to the head office. The pre inspection questionnaire indicated that, of a staff team of 42 people, 25 were qualified first aiders, and of a care staff team of 22 people, 14 were trained to NVQ level 2 or 3. A thorough quality assurance system was in use. Evidence was seen that an in-depth programme of auditing covered all aspects of the service. A business plan was made available to the inspector.
Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 17 Annual questionnaires were conducted with the residents and the results were analysed and used to improve and develop the service. The manager said that the residents’ views were also included in the residents’ newsletters. These were available to residents and their supporters. It was recommended that they also be included in the Service users’ guides. The managers said that additional feedback was received through residents meetings and from relatives, friends and others via comment cards that were freely available in reception, the comment column in the visitors’ book, and a confidential ‘post box’ that was only opened by the manager. The manager confirmed that policies and procedures were updated when necessary through the head office. Copies were provided and distributed in the home. Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 35 The policies and procedures are implemented and ensure that residents’ financial interests are safeguarded through good management. The risks to people from fire are reduced by regular checks of fire safety systems and staff training. EVIDENCE: It was observed that the residents’ personal monies were well managed. Records were well maintained and storage was acceptable. Monies were receipted in and out. No one in the home was an agent or appointee for any of the residents. Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 19 Standard 38 was not fully assessed but the pre inspection questionnaire indicated that a full range of safety checks and servicing of equipment and systems were undertaken. The building and services were well maintained and there was a programme of checks that were routinely carried out. It was observed that staff received training in health and safety matters. There was safe storage of hazardous substances and information was readily available to staff. The fire log indicated that fire detection and prevention systems were being regularly checked. There was a fire risk assessment for the home and staff were trained. Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x 4 x 3 x x x Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Wyncroft E55_S4891_Wyncroft_V246440_130905_stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Halesowen Local Office West Point, Ground Floor Mucklow Office Park, Mucklow Hill Halesowen, West Midlands, B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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