Inspection on 09/03/06 for Wyncroft House Nursing Home

This inspection was carried out on 9th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wyncroft House Nursing Home 04/09/08

Wyncroft House Nursing Home 24/10/06

Wyncroft House Nursing Home 13/09/05

Wyncroft House Nursing Home 16/02/05

Wyncroft House Nursing Home 07/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Wyncroft House Nursing Home 16 Moss Grove Kingswinford Dudley West Midlands DY6 9HU Lead Inspector Keith Salmon Unannounced Inspection 9th March 2006 1:15 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.V285289.R01.S.doc Version 5.1 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.V285289.R01.S.doc Version 5.1 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 wyncroft.house@ashbourne.co.uk the.willows@ashbourne.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) Mrs Wendy Averall Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (26), Physical disability (6), Terminally ill over of places 65 years of age (8) Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 2005 Brief Description of the Service: Wyncroft House Nursing Home is owned by Southern Cross and managed by Mrs Wendy Averill. The two-storey property is located in close proximity to the centre of Kingswinford Village and benefits from availability of local amenities and good public transport. Although the Home is registered to offer nursing care for a maximum of forty older people, some of whom may have a physical disability and/or need palliative care, two bedrooms have been taken out of use. Though the original house has been extended the building retains much of its original character. All bedrooms are single occupancy with communal bathroom and toilet facilities. The Home has no en-suite rooms. A shaft lift provides access to the first floor, and there is an attractive enclosed garden with ease of access for all Residents. Car parking facilities are located at the side of the property. Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection, undertaken by one Inspector, commenced at 1.15 pm and lasted 3.0 hours. It was the second Inspection of 2005/06 and looked specifically at ‘Key Standards’ not assessed at the previous Inspection held in September 2005. This Report is a product of observations made during a tour of the Home, through discussions with the Registered Manager, 5 Residents, 2 visiting Relatives and several members of Staff. In addition, a review was undertaken of care related documentation, staff recruitment/ deployment records and a range of documents/records reflecting the general operation of the Home. What the service does well: What has improved since the last inspection? What they could do better: Flooring in the corridor between rooms 11 and 21, on the first floor, has areas of unevenness and one area where a small section of floorboard ‘sinks’ up-to 1” when pressure is placed upon it - this must be surveyed to assess the nature/extent of the problem and remedial action taken. A recommendation, from the previous Inspection, that bedrooms are fitted with appropriate door locks to afford Residents privacy when they wish and secure their property when they are absent, has not yet been implemented. The Inspector was informed a quotation for suitable locks has been sought and these will, in the near future, be available for fitting to those bedrooms, where Residents request this provision. The low level bath in Bathroom 1, on the ground floor, needs to be replaced with one more appropriate for use by physically dependent Residents. Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 Page 6 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 House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 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 the following standard(s): 1,2,3,4 & 5. Prior to taking up residency prospective Service Users are enabled to reach an informed choice, and to fully understand the service they can expect to receive. Processes to ensure appropriate and thorough care needs assessment, prior to admission, are diligently and effectively applied. Staff in post are able to provide the type and quality of care required by Residents. EVIDENCE: The Home has a Statement of Purpose and User Guide, both of which are concise, easy to read and have content, which meets the requirements of the Standard. Service Users are provided with a Statement of Terms and Conditions detailing the accommodation to be provided. Evidence from 5 randomly selected Care Plans, and discussions with Residents and their Relatives, confirmed the Registered Manager, or Deputy Manager, assess all prospective Residents/Service Users prior to admission and new Residents have the opportunity to visit the Home, or enter the Home on a trial basis, prior to admission. It was noted the Home currently provides accommodation for 38 Residents despite Registration being for up-to 40 places as two bedrooms have been taken out of service. Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 Page 9 If this situation is planned to continue it is ‘Recommended’ a ‘Variation’ of Registration is sought, and the true position reflected in the Home’s Brochure and related documentation. Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 7,8,9 & 10. The care provided by the Home is effective in meeting the Residents’ assessed care needs, and delivered considerately and effectively. The general approach of Staff in providing such care is exemplary, with relationships between Residents and Staff being strikingly friendly and respectful. The storage, administration, and disposal of medicines are in accordance with accepted good practice. EVIDENCE: Care Planning documentation was well organised, current, clearly written and comprehensively encompassed the range of ‘care areas’ necessary to ensure the delivery of care appropriate to the needs of each Resident. Operational Policies and Procedures were found to be up-to-date and comprehensive. All accidents/incidents, however minor, are recorded in the Accident Book, with action and outcome, and none proved of particular concern to the Inspector. Inspection of the medicine storage provision, and medicine administration records, demonstrated the Home’s practices meet the guidelines of the Royal Pharmaceutical Society. None of the current Residents ‘self-administer’ their medication. Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 12,13,14,15. A range of leisure opportunities, consistent with Residents’ capabilities, is provided. The Home facilitates achievement of desired lifestyle, through Residents conducting the pattern of their day as they wish, including contact with family and friends, and continuation of religious practices. There is provision of a daily choice of attractive and nutritionally balanced meals. The Home is well integrated into the Community and its’ activities. EVIDENCE: The Home has a full and varied programme of activities, which are planned and organised by two ‘Activities Organisers’ who are employed for a combined total of 20 hours per week. These two ladies engage directly with Residents on a 1:1 basis and arrange activities which include local trips out with Relatives and/or Staff, regular visits to local shops and garden centres, involvement in themed days, e.g. St. Patrick’s Day, French Day, and visiting singers/ entertainers. Residents were very complimentary about the range, quality and choice of food provided, which is based on a four weekly cycle menu with flexibility to meet individual preferences. The local Public Library provides Residents with large print books and ‘talking tapes’. Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 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 the following standard(s): 16,17,18. The interests of Residents are protected through ready access to information relating to advocacy services and the Home’s Complaints Procedure. Staff are clearly aware of their role in protecting Residents from abuse. EVIDENCE: A clear and concise Complaints Procedure is displayed, which includes reference to the Commission for Social Care Inspection as the regulatory body, together with contact details. Information relating to the use of advocacy services is also displayed. Policies relating to the protection of Residents from abuse were observed to be in place and readily accessible, these included, ‘Whistle Blowing’, ‘Abuse Awareness,’ and ‘Adult Protection’. Staff training files indicated Staff had received training in respect of these Policies. The Home maintains a system for the recording of complaints, with none having been lodged since the previous Inspection. Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 19,22,24. Some aspects of the environment are potentially hazardous. In general, Residents’ bedrooms meet their own needs and preferences. However, there is no provision for Residents who may wish to lock their own rooms having been ‘risk assessed’ as being safe to do so. EVIDENCE: The flooring on the first floor corridor between bedrooms 11 and 21 has areas of unevenness and one area where a small section of floorboard ‘sinks’ up-to 1” when pressure is placed upon it. This must be surveyed to assess the nature/extent of the problem and remedial action taken without delay. The floor covering in Bathroom 1, on the ground floor, is split and presents potential tripping and infection control hazards. The covering must be replaced. In addition, the bath in this bathroom is of such a low level that it presents a health and safety hazard to Staff bending to attend to the bathing of Residents. It must be replaced with a specialist model, which meets the demands of bathing dependent Residents (e.g. a bath with adjustable height.) Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 Page 14 It is understood from discussions with the Manager and Residents that none particularly wish the facility to lock their rooms. Whilst it is accepted existing Residents may not wish locks, and the fitting of new locks to all bedroom doors in that circumstance may be an excessive expense, the facility should be in place to fit a lock, at short notice, should a Resident change their view or a new Resident wish the privacy and security of a door lock. A Requirement will be made to this effect. Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards in this section not fully assessed at this Inspection. EVIDENCE: Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38. The Home’s Health and Safety Policies/Procedures/Practices were found to be generally satisfactory. EVIDENCE: With the exception of the issues identified under assessment of Standards 19 & 22 (above) COSHH requirements were satisfactory, with maintenance and servicing of equipment regularly undertaken, and appropriately documented. Records are maintained for hot water supply to baths, and water tested during the Inspection was satisfactory and COSHH data sheets are up to date. Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 Page 17 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X 2 X 2 X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? YES 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 OP19 Regulation 23.-(2)(b) Requirement The flooring on the first floor corridor between bedrooms 11 and 21 must be surveyed to assess the nature/extent of the unevenness/ sinking. N.B. An ‘Immediate Requirement’ Notice has been issued with regard to this ‘Requirement’. The Responsible Person must submit to CSCI a plan of action to remedy the issue identified in (No.1.) above. Undertake repair/remedial work as identified in (No.2.) above. Replace/repair the floor covering in Bathroom 1 on the ground floor. Replace the bath in Bathroom 1 on the ground floor with a specialist model which meets the demands of bathing dependent Residents (e.g. a bath with adjustable height.) Timescale for action 18/03/06 2. OP19 23.-(2)(b) 31/03/06 3. 4. OP19 OP19 23.-(2)(b) 23.-(2)(b) 30/04/06 30/04/06 5. OP22 23.-(2)(n) 30/04/06 Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 Page 19 6. OP24 12-(3)13(4b)23-(2a) The Home must have available the facility to fit an appropriate lock to a bedroom door, within 24 hours of receiving such a request from a Resident. To facilitate this the Home should have a minimum of two such locks on site to enable fitting at any time. 30/04/06 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 It was noted the Home currently provides accommodation for 38 Residents despite Registration being for up to 40 places. If this situation is planned to continue it is Recommended a ‘variation’ of Registration is sought, i.e. to change the number of Registered places to that which accurately shows the maximum number of places offered. Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wyncroft House Nursing Home DS0000004891.V285289.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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