Inspection on 04/09/08 for Wyncroft House Nursing Home

This inspection was carried out on 4th September 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

Wyncroft House Nursing Home 24/10/06

Wyncroft House Nursing Home 09/03/06

Wyncroft House Nursing Home 13/09/05

Wyncroft House Nursing Home 16/02/05

Wyncroft House Nursing Home 07/06/04

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Heathlands

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Ravenhurst

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Inspirations

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Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

CARE HOMES FOR OLDER PEOPLE Wyncroft House Nursing Home 16 Moss Grove Kingswinford Dudley West Midlands DY6 9HU Lead Inspector Tina Smith Key Unannounced Inspection 08:40 4 and 5th September 2008 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 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 wyncrofthouse@schealthcare.co.uk www.schealthcare.co.uk Exceler Healthcare Services Limited Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Michael Lawson Care Home 40 Category(ies) of Dementia - over 65 years of age (8), Learning registration, with number disability (1), Old age, not falling within any of places other category (26), Physical disability (6) Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To accommodate one named service user within existing numbers under the age of 65 years and with learning disability. That the service users with a Dementia may 55 years and over. Date of last inspection 24th October 2006 Brief Description of the Service: Wyncroft House Nursing Home is owned by the Southern Cross Healthcare group. Accommodation and nursing care for people with physical health conditions, and specialist dementia care services (8 places for personal care) are provided to a maximum of 35 adults. The two-storey property is near the centre of Kingswinford Village where there are local amenities and public transport. There is a car park at the side. The original house is used mainly for dementia care and staff offices, and has a small enclosed garden. There is an extension used mainly for nursing care, with a dining room and access to a large back garden. There are 36 single bedrooms, none ensuite, accessed by a passenger lift. The home reduced their registered rooms, and one is now used as a viewing room for people looking around the home. There are communal toilets, assisted bathrooms and shower room facilities throughout the home. Pets are considered. There are two birds, a guinea pig and a fish tank in the dementia care unit. The home currently charges between £362 and £615.69 per week, depending on the level of care required and the accommodation, and any NHS funding for nursing care. The charge does not include extra services such as dry cleaning, hairdressing, chiropody, physiotherapy, aromatherapy, reflexology, and a staff escort to pre-arranged health appointments. The fee information given applied at the time of the inspection; up to date information should be requested from the service. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. Our inspections focus on the outcomes for people who live in the home and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, national minimum standards of practice, and on aspects of service provision that need further development. Before the fieldwork visit took place a range of information was gathered from the last key and thematic inspections, surveys from people in the home, their relatives and staff, things the home and others told us about, and a questionnaire the home sent to us, called the Annual Quality Assurance Assessment or AQAA. This gave us some information about the home, staff and people who live there, improvements they have made and intend to make. Visits were made to the home by one inspector over two days, totalling 15 hours. The home did not know we were coming. On the first day we also arranged for an Expert by Experience from a voluntary organisation to visit the home for three hours. The Expert has personal experience of dementia and care services, and is trained to talk to people and their visitors, observe their experience in the home, and prepare a report. This helps us assess the quality of care in the home for all people, but also those who find communication difficult, and to understand how the staff and environment affects people’s wellbeing. Three people were ‘case-tracked’. This means we met or observed people and areas of the home that they use, looked at their records, medication, and equipment in detail. We checked what staff knew about them, their needs, and how care is provided. Other people’s medication records were sampled. People who live at the home, staff and several visitors were spoken to. We looked around the building to make sure that it was warm, clean, comfortable and secure. The Expert watched and shared a mealtime with people at the home, and the inspector watched breakfast and medication administration. Records about running the home and managing staff were seen. One requirement made at the last inspection has been met. There were no immediate requirements after this visit. This means that there was nothing urgent that needed to be done to make sure people stayed safe and well. There are 6 requirements and 14 good practice recommendations made as a result of this inspection. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? A viewing bedroom was set up and the service user guide and statement of purpose were updated to help people decide about the home. Extensions to profiling beds are provided to meet people’s needs. The Manager is the home’s ‘Dignity Champion’ in partnership with a Dudley Primary Care Trust initiative to improve dignity in care and health services. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 7 Staff were trained in end of life care by MacMillan Nurses to improve respect and pain management. ‘Life diaries’ are in use in the dementia unit to understand more about people. The home has a new minibus because people wanted more outings. Recruitment of new staff to cover vacancies is nearly complete. There is now one dedicated night staff for the dementia unit to improve consistency of care. A new manager was registered by CSCI. What they could do better: Written and website information about the home needs to be accurate to help people make an informed decision about the home’s suitability. Two people told us they are not able to maintain their abilities and independence; they have lost muscle tone as they have not had access to physiotherapy. People and relatives are generally satisfied at Wyncroft but told us that: “The care provided is very good but the low number of staff on duty make the service at times poor.” “Meal times are very erratic…” “Just because someone is in bed it doesn’t mean they don’t need additional attention.” Management need to take exceptional circumstances in the home into account and review staffing arrangements. People in both units do not have enough control of their lifestyle because they have to wait a long time for care and/or food. There is disruption to both units when they are brought together because of staffing arrangements, and there are times when both units are un-staffed because staff are needed elsewhere in the building. Some people need constant care or oversight because they pose risks to others and themselves. The dementia unit has insufficient space for the number of people and visitors using it. The design and layout of the building and service, places restrictions on people’s lives. There is a claustrophobic effect on people, increasing ‘ructions’, agitation and the need for reassurance, and the unit can be noisy. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 8 There is not enough physical and mental activity for people in both units. There are people isolated in their own rooms, and only a few people in the nursing unit can see the tv or have been offered outings. People told us they have been distressed by the continence care provided by some temporary staff that was degrading. Recruitment checks need to confirm all staff on the premises are safe, are briefed to work in the home, and are sufficiently trained to meet people’s needs with dignity. Temporary staff are also posing an infection control risk to the home that needs managing along with an odour in the dementia unit corridor causing complaints as it is unpleasant and unhygienic. There are other risks that management need to assess and monitor to improve security arrangements, fire evacuation, and regarding pets so that people are safe and maintain their health. Continued professional development needs to help staff agree on clinical consistency, and keep staff up to date so that people benefit by best practice and protection of their new legal rights. Staff do not feel valued and supported by management and are upset that they cannot provide the care that people expect. There needs to be more accountability for the system of auditing people’s money so that people’s financial best interests are protected. People and relatives feel that little changes when they voice concerns. Management systems are responsive but are not proactive; contingencies need to be formed and made accessible to key staff so that the home runs smoothly, preventing some concerns arising. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 – 5: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Everyone has an assessment, a visit or trial, a contract and the home confirms whether needs can be met. Information is available to help people make decision about the home’s suitability, but it is not accurate. EVIDENCE: People and families have the opportunity to visit and have a trial at the home before making a decision to live there. Everyone has a pre-admission assessment of their needs and equipment by trained staff. The home confirms in writing whether people’s needs can be met. A care plan is prepared about how health and care needs will be met, which is kept under review. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 11 Staff at the home are skilled and knowledgeable. There are trained nurses and care staff to meet people’s needs. The home does not provide intermediate care services. There were 29 people in the home when we visited, including two people for short stays and the dementia care unit was full. Nine people are cared for in the dementia unit during the day. The additional person does not have dementia but is assessed to benefit from activities in the dementia unit, but we saw no activities held. Two people with dementia have bedrooms in the nursing care unit, and two people needing nursing care have bedrooms in the dementia unit. People told us they had enough information about the home, and one person used the CSCI website to view the home’s inspection report. There are contracts for the home’s fees, as well as for those who want the home to manage money and personal spending. This is good practice, however the contracts did not all legibly identify the names and roles of the representatives signing contracts. There are letters when fees change, but they do not include the date changes take effect. Clarity is important so that people can budget for this. We saw an up-dated service user guide and statement of purpose with a lot of useful information about the home, available in large print. Other formats and languages would also make it more widely accessible. On one page the guide refers to another home, not Wyncroft. Southern Cross Healthcare have a website, but the information about Wyncroft does not match the home’s registration and does not show that dementia care is provided. The home’s written information explains general services and facilities so that people know what to expect, i.e. nursing, personal and social care, the fee range, admission process, fire and complaint procedures. There is no information about the specialist dementia care service. People will not have enough information to make an informed decision about Wyncroft’s approach, the extent to which staff are trained in dementia care, and the way this unit is run. There were 40 admissions in the last year and two placement breakdowns. There was a complaint that the home assessed and confirmed a person’s dementia care needs could be met, finding after admission that their needs were greater than the home could meet and they had to move again. There are people in both units at Wyncroft with fluctuating decision-making capacity, and some people fund their own care. There is information on local advocacy services including statutory advocates. Staff are referred to as ‘advocates’ in the home’s public information, which will confuse people and staff. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 – 11: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems ensure people’s personal care and health needs are usually met, with respect and privacy. The medication system is well managed, so that people are protected. There are changes needed to maintain people’s abilities, dignity, and to improve the emotional wellbeing of people with dementia. EVIDENCE: Three people were case-tracked at this visit, and other medication records were sampled. Each record has a detailed and individual care plan, with equipment and instructions for staff about how needs are to be met. Plans are agreed with the person, and a representative with their consent. There are competent staff who showed us they know people and their needs well, including their likes, personal routines, moods and guidelines they work to. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 13 Risks are assessed and interlinked, such as increased risk of pressure sores if people aren’t mobilising or eating and drinking enough. Personal care is discreet, in accordance with people’s wishes about how often they bathe and the gender of staff, and we saw people’s privacy respected by knocking on doors, providing a bathrobe to someone wandering. There are regular reviews and evaluations of care, treatment and its’ effect on health and wellbeing, but not these do not all include the environment and restrictions on people’s lives (see environment section). People’s views, those of their representatives and professionals are acted upon. There is respect for people’s rights to take risks, refuse care, aids and medication. One person was encouraged to dress and socialize in the lounge for a time at the family’s request, but their discomfort from pressure sores led to a change of plan to promote healing. In another situation care plans have clear guidance for staff depending on the person’s mood, to prevent isolation, falls, and to manage healing when the person removes dressings for pressure sores. Staff told us that they are managing more complex conditions. Last year nurses had training by MacMillan Nurses in end of life care. We saw good end of life care in one record identifying the person’s religious needs, interests, important relationships, an advance decision and their wishes. Nutritional needs, pressure area care and pain management are planned and met, and this is reviewed daily if necessary. Monitoring measures are used, such as people’s weight and body mass index, charts for turning, continence, catheter care and peg feeds. There is safe equipment and detailed guidance for safe mobilising and safe handling techniques. Health appointments are kept. There is clinical oversight and audits. We saw the following good practice: • close observation records for people with progressive and complex conditions subject to rapid deterioration • care plans about specific health conditions, such as diabetes • medication and clinical guidelines for people on warfarin, digoxin • individual wound plans • nutrition plans identifying likes and dislikes, using fortified food and food supplements and the advice of dieticians and specialists if there is swallowing difficulty. • care plans for people presenting behaviour that poses a risk to themselves and/or others using de-escalation techniques. The Expert by Experience confirmed other information showing us that people and their relatives have a high regard for the staff but that their dignity and abilities are not always maintained: “Care is excellent when staff are available…[people and relatives report]…waiting 30 to 45 minutes before being taken to the toilet … Two of the residents …felt that additional physiotherapy would have helped them to be Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 14 more independent and mobile. This had not been incorporated into their care plans. They felt nothing had been done to encourage them to maintain the muscle tone they already had…[staff] are playing ‘referee’ rather than providing activities, to avoid a major incident with increasing aggression in the dementia unit…“staff were genuinely upset they cannot provide the service they would like”. Most of the surveys made similar remarks, and raised concerns. One relative wrote: “[Staff]…can only be in one place at one time; many times they are needed in more than one place. There should also be a member of staff at all times in the lounge (very rare there is due to lack of staff). I have seen people fall from chairs, cry for toilet, need drinks, etc” We saw people in cold bedrooms and in dining rooms, waiting for assistance and food in both units. One person nursed in bed, with severe pressure sores was calling out for help. They are unable to use the call system and are only able to make noises; this could not be heard behind their closed bedroom door. No staff were available. We saw a behaviour management plan developed after one person with dementia harmed others and property. The plan maximises cooperation, and has contingencies for the person’s moods. It is recorded that this person needs constant care and attention. We found good falls prevention in the home and there are few falls. People’s health and care needs are generally met, but the experience for people in the dementia unit, including an extra person without dementia, is likely to be affecting their emotional wellbeing and safety. There is professional diversity about how to improve this for individuals. Families are involved daily in feeding and shaving relatives, and in one situation help to administer medication. There need to be agreed risk assessments and care plans about regular family involvement, and we did not find any. One relative was given a person’s medication, and reported back whether the person took it successfully. There was a real partnership in meeting the person’s needs, and their condition is improving, however medication records (MAR) are completed by nurses about medication they did not administer or oversee, or that are refused, and are making themselves accountable for records that could be inaccurate. The MAR should indicate who attempted or administered the medication. The home have liaised with doctors regarding this person’s swallowing reflex and about liquid medications. In other respects a safe medication system is maintained, with regular internal and external audit. Nurses and Senior Care administer medication. Staff need to use consistent codes in medication administration records (MAR) – management changed staff guidelines when this was brought to their attention. We discussed the need for clinical consistency regarding administration of digoxin according to the guidelines written on the MAR. If medical advice is sought, the MAR should reflect this. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12-15: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People have choices to remain in control of their lifestyle and beliefs, but this may not match daily expectations. Relationships are maintained with families. Food is healthy and highly praised. EVIDENCE: There are opportunities for people to manage their finances and medication. Food likes and dislikes are recorded, and the cook is usually but not always informed about dietary needs. Preferred names are used, staff know how people like their hair styled, and what they like to talk about. Religious needs are met in the way people want. Assessment of sexual orientation lifestyle needs is less well developed. Life Diaries are used in the dementia unit to find out more about people’s histories, and are used along with photographs for communication and activity plans. There are activities people can occupy themselves with. The nursing Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 16 unit has little for people to do or look at. The Expert told us that the television in the nursing unit lounge can only be seen by a few people. People in this unit do not have activity plans, but their interests are known. A relative said, “Just because someone is in bed it doesn’t mean they don’t need additional attention.” Management are aware that people nursed in their own rooms do not have enough attention and social contact. There are no plans about how this will be improved. There is an activities coordinator and people told us there are activities sometimes. Monthly there are themed days, such as “blue day.” We did not see people being physically and mentally stimulated in either unit on our visit. One person said, “I’d like to go out sometimes.” The home has a minibus that can take one wheelchair, and there is some discontent about who is chosen for outings. Exercise has been planned but has not yet started. Views were expressed to the Expert about noise levels, friction and a lack of acceptance and unkindness by some visitors to people with dementia, who are unable to defend or control themselves. “Bedlam” was used to describe late afternoon/evenings when the dementia unit is full with people, visitors and pets. We saw the birds covered at one point to calm the atmosphere. Some people in the dementia unit had one to one staff attention at times to prevent ‘ructions’, so organised activities could not take place as planned. The garden was not used during our visit. People have short attention spans and their needs change as their condition progresses, so some of the puzzles, for instance, we are told now lead to frustration. This is a circular situation – if there was more activity, challenging behaviour and agitation may reduce. People experience many upsets daily in the dementia unit. People told us the food is usually good. There is a corporate 4 week rotational menu with regional variations. There are trials of new recipes and foods; a cook recently came second in a national company competition. Meals and drinks have sometimes not arrived or are late; there have been some food or choice shortages, such as coffee and for soft diets. We did not see any snacks or refreshments people can help themselves to, but snacks were served. Visitors are often in the home, seeing or helping relatives and friends and taking people out. One person has staff help to receive telephone calls from a relative living abroad. Visitors can dine, with notice and for a charge. Food is nutritious and there is choice at every meal. Staff give people clear information and prompting so that they make choices about food and remember to eat. We saw people fed at their own pace. Relatives all told us how the staff supported people well when available. The Expert reported, “…clearly there is a good rapport between the residents and staff…staff very patient and affectionate (i.e. smiling, holding {people’s] hands…chatting to them in a calm, cheerful manner). The residents responded in a positive way…” Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 17 One relative told the Expert there were more staff on than usual on our first visit, yet the Expert observed that staff are ‘over stretched’ in the dementia unit, at dinner time. There was unexpected short staffing on our second visit. People are left alone in both lounges at times, especially if two staff are needed to manage equipment. People waited on both sides of the home for staff to assist them to get up, and the call system was buzzing for long periods throughout the first day of our visit but not the second. The home’s guide strives to meet personal preferences but makes clear this is dependent upon staffing and the needs of other people in the home. We found that the home is run with daily flexibility to manage unexpected short staffing and around the current home layout, rather than meeting people’s assessed needs and expectations of flexibility by choice. Some people are not able to maintain their abilities and independence. Systems need to ensure that people’s special dietary needs are always met. This includes people with conditions such as diabetes, where a long time gap between meals and medication can be detrimental to their health. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 – 18: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are encouraged, listened to and learned from, but there is an unresolved complaint affecting the home. People feel safe and are protected from abuse by training and systems in place, but checks on staff need to improve. Some legal rights are protected. EVIDENCE: There is an open culture so that people and visitors feel able to raise their views and concerns with staff, and there were 18 formal complaints since the last inspection. Management responded within timescales, learned from them and tried to make changes that families are satisfied with. One example concerned the lift breaking down and how needs were met during a delayed repair. There is now an evacuation procedure. Staff practice was changed after a complaint about lack of staff in the lounge, but we also heard from families that this still occurs. There were a number of complaints about staffing and care, and some were upheld. There is an unresolved complaint that current management inherited from 2007. This matter is hampering care delivery and staff availability in the home daily, which is preventing people having full control of their lifestyle. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 19 Some concerns by people and families in records and minutes were not treated as formal complaints. These included missing laundry, whether there was timely action taken to prevent falls and aggression, and continued concern about an odour. A sample of company policies and procedures from 2006 and 2007 protected people’s legal rights in general, e.g. to vote and have access to their records, but they are not fully up to date. Some staff had training about new mental capacity law, but we found staff are not up to date on who can consent to bedrails and behaviour plans, and about their roles in making and recording best interest decisions. Abuse is taken seriously at Wyncroft. We saw Elder Abuse Hotline posters, although to use a phone, staff assistance needs to be sought. People continue to be protected as staff attend and refresh training, understand and follow abuse and whistle-blowing procedures. A few people in the home reported concerns about their handling at night by temporary staff. The home worked well in one situation under multi-agency protocols to safeguard people and investigate. People feel safe but one person in tears described to the Expert continence care that appeared degrading, from temporary staff the previous evening. On the second day of our visit we learned something similar happened overnight. We checked staff recruitment records and discussed improvements needed with management: • • • to checks the home make to ensure that permanent and temporary staff are safe to work in the home to confirm that temporary staff have the right experience and training to meet needs of people in the home to ensure that temporary staff are briefed on people’s needs and the home’s expectations of how these are to be met. Management confirmed with us during and after the inspection, that appropriate action was taken to confirm people are in safe hands, and to prevent poor practice and distress to people in the home when temporary staff are necessary. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19-22, 25, 26: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People can bring their own possessions and equipment suits their needs. The home is clean and generally well-maintained but there is an odour in the dementia unit. Hazards in the grounds pose safety risks. Insufficient space in the dementia unit is affecting people’s wellbeing and safety. EVIDENCE: Impressions of the environment by the Expert confirmed our own view: “The home is split in two parts…the dementia unit [is] decorated with interesting features…such as the historical regional photographs and trips…This was in contrast to the nursing unit which was very clinical in its decoration... Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 21 [in the dementia unit] was the strong smell of animals and urine. The Home Manager explained that the carpet had not been cleaned due to problems with the shampoo cleaner… The nursing unit has a large, airy open plan lounge split by a small dividing wall, where residents spend most of the day. There is a television in one corner…which can only be viewed by those…sitting in that…area… lack of space in the dementia unit…no quiet area… dining tables [for] 8 people… Due to the claustrophic nature of the room…ructions… happened on numerous occasions during my time on the unit … buzzers were ringing for long periods…the nursing home was cold and the windows were open…All the residents and family carers were happy with the cleanliness…the laundry service, and reported maintenance issues were dealt with quickly and effectively. ” The physical design and layout of the home and its’ facilities are not meeting all the needs of people the home is registered for; improvements are necessary. Current management inherited the layout, and options tried have focussed on views of more able and vocal people. The views and best interests of people with more limited communication, and sensory disabilities are not known to management or recorded. The dementia unit has insufficient communal and garden space for the number of people and visitors regularly present, and their needs, and this may be exacerbating agitation and aggression. There are limitations on movement and on liberty by internal and external security coded and locked doors. The pets should be the subject of the home’s risk assessment and audits to prevent risks, such as alveolitis. We would recommend hearing loops in communal areas to improve acoustics for people with hearing aids. We saw hazards in the grounds known to management that have not been addressed. The back garden poses safety risks for people unescorted, as the grounds are less well maintained and equipment is lying around. We observed a fire drill and noted that the pile of disused furniture and equipment at the front of the nursing unit could impede the fire service and evacuation of people in wheelchairs. We noted security risks from two sources. Room temperatures are within a safe range where medication is stored but the window was open and did not have a restrictor. If the room is unoccupied, this could pose an intruder risk, and risk to the wider community if drugs go missing. Visitors knew the security code to enter the building, and audits note that visitors do not always sign in. The home’s security and fire safety precautions are insufficient. The home is clean, and smells fresh except in the dementia unit. There are infection control audits, clear infection control plans for individuals, and there has been no outbreak of contagious infection in the home. We queried infection control risks from the lack of a liquid soap dispenser in one bathroom, toiletries found in another bathroom and from urine disposal by temporary Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 22 staff. There are two separate sluices; clean and soiled laundry are separated. The kitchen is exceptionally clean and hygienic, with good record keeping for food storage safety, and stock control. The home is working on a council food hygiene award. The temperature of cooked food is tested for safety; a new probe has been on order for sometime. Maintenance records, health and safety checks and audits sampled are up to date. Other regulators found no requirements needed when they last visited the home. Although bedrooms are not ensuite, there are sufficient toilet and assisted bathing facilities. Rooms and equipment suit people’s needs, are well maintained and there is storage space. The weather turned exceptionally cold the day of the inspection. Staff and management did not notice how cold it was in the home with the windows open, and after some time we drew this to their attention with concern for people in bed. The heating was put on and an engineer was called when a problem with the heating system arose. We were told the older part of the building is usually cold in winter. The staff room had a broken window, permanently open. We note there have been problems with the new call system. During the inspection this affected noise levels and the atmosphere. We found that management do not proactively plan contingencies, for example about delays from suppliers and repairs. A temporary replacement carpet cleaner was not sought to maintain hygiene and odour. One-off problems about food and crockery supplies occur and systems are not detecting this. A survey in 2007 told us that there is sometimes shortage of clean bed linen”. We checked and found a very limited stock in cupboards, but the laundry is run 7 days a week. We checked bedrails, bumpers and care plans that prevent entrapment and found this to be safe. We saw profiling beds, extended at relative’s requests, appropriate pressure relieving equipment and pressure mattress settings determined with an NHS specialist. We saw good practice, including inventories, management action to improve laundry labelling and distribution, individual fire evacuation plans, and refurbishment plans that will be responsive to requests such as “visitors chairs no longer comfortable and too few.” For privacy, bedrooms have door locks, a lockable drawer, and the home’s guide indicates a lockable facility is provided if people self medicate. Management took action to some matters raised during the inspection, and said they will consider options to improve the layout. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27-30: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment checks of all staff on the premises need to confirm that people are in safe hands. Staff should be available when needed. Permanent staff are experienced, trained and have a person-centred approach, but opportunities to update professional practice could improve. EVIDENCE: People and relatives told us: “All staff are excellent, thoughtful, caring & helpful but not enough of them. I don’t know how or why staff continue to work under such conditions!” “Agencies are not very good – don’t know the resident’s individual needs.” The manager told us that staffing was reviewed following our thematic safeguarding inspection in 2007 - dedicated night staff are provided for the dementia unit; there is extra staffing at mealtimes. We learned that this is not sufficient. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 24 Three evenings/nights are currently staffed so the dementia residents are able to remain on the unit. When staffing levels are low the dementia residents are taken to the nursing unit as it has more staff. This has led to disruption of people in the nursing unit lounge. There are times when both units are left unstaffed, when two staff are needed to assist a person safely with equipment in their rooms. The effect on people is noted in other sections of this report. The Expert reported to us that staff were overstretched in the dementia unit during the dinner observed. Relatives told the Expert there were more staff on duty than usual during the inspection; on the second day there was staff sickness and no cover arranged. A variety of information indicates this is a regular occurrence. Staff sign a European Directive waiver regarding hours of work, and told us they agree to cover extra hours so that people have consistency of care. We did not see risk assessments in staff files about staff fitness regarding extra hours. A planned staff meeting to discuss issues was due to take place the first day of the inspection, and was cancelled. There has been a lengthy period of staff shortage in the home, we are told due to the lack of suitable staff locally, but the home are in the final stages of recruitment checks and have filled all vacancies. Temporary staff from agencies regularly supplements the staff team. The Operational Director told us that the home is better staffed than other similar homes in the company group. A dependency scoring tool is used to base staffing on people’s needs. This tool does not capture the home’s exceptional circumstances: allocation of bedrooms, current layout and use of the home, an extra person cared for in the dementia unit, and environmental effects on people. Current staffing arrangements are not improving outcomes for people in the home’s care, and need ongoing review. The AQAA told us there are rigorous pre-employment checks. We sampled three staff records and needed to raise queries to ensure that people are in safe hands at all times: • • • • about international police checks about clear vetting checks being confirmed with Head Office before new staff commence unsupervised duties about written confirmation that temporary staff have appropriate checks, experience and training to meet the needs of people in the home about the briefing of temporary staff so that they understand people’s needs, expectations and systems of the home, for instance about dignity and infection control. The home would benefit from a good practice policy about renewing checks of long-standing staff. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 25 Permanent staff are experienced, trained and have a person-centred approach. Everyone has an induction to safe working practices, customer care and abuse. The number of NVQ qualified staff and supervision exceeds national minimum standards. Staff competency is checked and there are regular performance appraisals. We did not see staff development plans in the home’s records. Mandatory and refresher training is largely computer based, with exams. Staff do not find this as useful as their manual handling training. Staff told us that training doesn’t meet their needs or match people’s conditions, and there are few opportunities for professional staff to keep up to date. Dementia care and managing aggression was of particular concern. We found that the home has trained most staff in dementia awareness and managing challenging behaviour. We saw staff using best practice, deescalation techniques and we saw good behaviour plans after aggressive incidents. More advanced dementia care training was provided last year to Senior Care, and another course is taking place soon. Management are planning but have not introduced ‘peer review’ through case discussion, for professional development. Nurses had palliative care training. A staff member has holistic therapy training, and one is trained to provide personalised funerals after requests from relatives. Nurses would benefit from clinical guidelines, updates and learning opportunities matching people’s conditions, such as tissue viability, either through the company or often available to care homes through local links with NHS Trusts. All staff need to learn about and apply new codes of practice relevant to mental capacity and mental health law. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 – 38: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management seek people’s views, and check quality standards. People’s financial interests are protected. Communication with staff and plans that assist smooth running of the home need development and timely action so that health, safety and welfare is promoted and protected. EVIDENCE: The home has an experienced and qualified manager who is a registered nurse. Everyone finds the manager approachable and says that he and the company invite views and opinions. During the inspection staff frequently Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 27 sought and received advice from the home manager and care manager, who provides supervision and regional mandatory training. The AQAA was completed on time and provided us with required information. The manager is improving and developing systems that monitor practice and compliance with the plans, policies and procedures of the home. More work is needed in this area. There are a number of ways that quality of the care is checked; some findings are available in reception. For example, staff and relative meetings are held so they can voice concerns and suggestions for improvement. The AQAA told us that a minibus was purchased so that more outings people asked for could be provided. We found that people in the nursing unit still have few opportunities for outings. There are consumer surveys; people do not always want to meet to express their views. We were told that the Activity Coordinator sees people personally but we saw no record of this. The Expert told us about a person with dementia who likes to talk about improvements to the unit. People, relatives and staff had mixed views about whether management act on views expressed. They are often told that changes depend upon budgetary concerns or a response by the company or suppliers to requests and delays. Proactive contingency plans are needed that key staff can access to ensure the smooth running of the home. Systems need to ensure food staples, sufficient crockery and linen stocks are checked and available. This may prevent some of the concerns arising. Communication channels for reporting and acting on day to day matters can also improve. A ring was found, but no one was clear on how to find its’ owner, so it was just put in the safe and the manager was not informed. The home manages money for people who need assistance with their personal allowances. There is a new computer-networked financial system, and receipts are kept. Few people or relatives request a statement of their account, making it important that an accountable person audit whether people’s money is being spent in their best interests by staff. A small discrepancy was investigated by the company, no cause found but it was not reconciled until we queried it. We discussed during the inspection with management how people’s financial interests can be further protected by the home. Regular health and safety, and quality spot checks are shared by the operations manager and the home’s manager; audits are delegated to other staff are countersigned by these managers. Environmental hazards need to be prevented and acted upon in a timely way for people’s safety. Audits are not capturing all matters. Systems should ensure Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 28 There is a privacy and dignity policy, and the manager is now the home’s Dignity Champion in a borough wide NHS Trust initiative. This has not changed people’s experience in the home. Concerns identified in sections on health and personal care, complaints and protection and staffing should be addressed swiftly by the management team. The company have been sluggish in resolving the matters preventing full introduction of a unitised approach to Wyncroft’s diverse services. New law now requires that least restrictive options are applied to the home’s layout and service design, so this needs a careful and creative review. Staff morale is low, and they do not feel valued by management. The Commission has not been notified of staff shortages. Notification is required so that we can monitor the home in between inspections. The manager told us in the AQAA that the home has a committed workforce and the company are developing a staff retention plan. Management know what they want to improve, including the quality of people’s lives to their wishes, and staff professional development, but staff are already overstretched. Management need to review the basis on which staffing decisions are made to ensure sufficient staff are available daily for people’s needs and the exceptional circumstances in the home. Needs and circumstances change, so this must be kept under review. Staff cannot be in two parts of the building at once, nor can vulnerable people be left unattended for long periods. Night staff need the same skills and training as day staff to meet the needs of people in the home. There are regular audits of incidents, accidents, complaints and concerns that take preventative action and promote learning through staff meetings or by policy development. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 2 18 3 2 2 3 3 X X 3 2 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 2 2 3 2 Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13(2) Requirement The registered person must ensure that medication administration records are accurate, reflecting who actually attempted or administered the medication when family or friends contribute to the person’s care. The registered person, after consultation with the council health and safety officer, must ensure that the size and layout of rooms used by people in the home are safe and suitable for people’s needs and best interests. The registered manager must ensure that intruder and public safety risks are identified and managed appropriately so that the building is secure. The registered person, after consultation with the fire authority, must review the home’s fire risk assessment and take appropriate action regarding any hazards in the grounds so that people have an adequate means of escape. DS0000004891.V371381.R01.S.doc Timescale for action 04/12/08 2. OP19 23(2)(f) 04/03/09 3. OP19 13(4)(c) 04/12/08 4. OP19 23(4)(b) 04/12/08 Wyncroft House Nursing Home Version 5.2 Page 31 5. OP29 19(4),(6) 6. OP29 18(1)(a), 18(4), 19(5) The registered manager must 04/10/08 ensure there is a thorough recruitment process before permanent and temporary staff are used in the home so that people are protected. This must be available at the home for CSCI inspection. The registered person and 04/12/08 manager must ensure that there is suitably qualified, competent and experienced permanent and temporary staff in sufficient number as is appropriate for the health, welfare and safety of people using the service. This must be kept under continuous review and consider exceptional circumstances in the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The statement of purpose, service user guide and website should accurately describe the home and all services the home is registered to provide, so that the public has clear information to make an informed decision about suitability. Contracts should legibly record the name of parties and the role of representative signatories, so that duties in respect of mental capacity law are clear and the person’s legal rights are protected. Where family or friends are regularly involved in the care and/or medication of an individual, this should be risk assessed, agreed with them, recorded on the care plan, and kept under review. Systems should ensure that people’s abilities, muscle tone and special dietary needs and risks, such as long meal gaps, are assessed, planned for and maintained to maximise people’s health, independence and quality of life. Management should review whether there is DS0000004891.V371381.R01.S.doc Version 5.2 Page 32 2. OP2 3. OP7 OP9 4. OP8 Wyncroft House Nursing Home 5. 6. OP8 OP12 7. OP14 OP33 8. OP17 9. 10. 11. OP19 OP22 OP26 12. 13. OP30 OP35 14. OP38 sufficient access to NHS physiotherapy services. Any risks to people’s health and wellbeing from pets needs to be identified and as far as possible eliminated for individuals, and be monitored by management. Equipment and arrangements for individual and group activities and outings that suit people’s interests and abilities should be reviewed. Systems for recording and auditing opportunities made available, and individual take up will help management evaluate how they are meeting people’s assessed needs for social stimulation and physical activity. Isolation of people nursed in bed should be prevented if this is not an informed choice. It is recommended that the home uses local or national good practice guidance to draw up and progress a dignity plan with people in the home. This can be used in the home’s quality assurance system to monitor people’s views of their experience in the home. It is advised that codes of practice relevant to mental capacity law and deprivation of liberty are used to review the design and layout of the home, policies and individual restrictions so that people’s rights to least restriction are maintained. Records are required as in Schedule 3 (q), Care Home Regulations 2001 The grounds should be maintained and safe for people in the home to use unescorted. The home’s development plan should include a review of facilities to maximise the ability of people with sensory disabilities to communicate and have social stimulation. It is recommended that best practice guidance on infection control and the management of incontinence in care homes is obtained and used to further improve hygiene, odours and infection control measures. Continued professional development should address clinical consistency, meet people’s changing needs using best practice and keep staff up to date with legal changes. The financial best interests of people should be fully safeguarded by accountable signatories, management checks, company systems and policies. Discrepancies should be investigated and acted upon. The manager should ensure there are systems and contingency plans in place, known and accessible to key staff to ensure the smooth running, safety, sufficient heating and hygiene in the home. Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wyncroft House Nursing Home DS0000004891.V371381.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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